Clinical Encounters: Lift

Physician Peer Support

Activities Physician Peer Support Overview & Key Points Physician Peer Support

Read as PDF (alternate format)

Download PDF

Read as PDF (alternate format)

Apply Skills from this Module

Scenario: Jeffrey T

Module Introduction

The practice of medicine is often full of stresses that can add up to have harmful physical and emotional effects. Many reports have found that these stresses and their impact have increased in recent years (Panagioti, et al, 2017; Patel et al., 2018; Alexander et al., 2018;). The following symptoms of burnout that have been reported by physicians in a variety of studies over the past 10 years (Jackson et al., 2016; Oreskovich et al., 2015; Mota et al., 2013; Bohman et al., 2017):

  • Emotional exhaustion
  • Alcohol use problems
  • Poor sleep
  • Excess weight
  • Insufficient exercise
  • Low sense of personal accomplishment
  • Interpersonal disengagement
  • Health problems

Fortunately, there are things that you can do to reduce and manage the personal impact of the stresses you face. One very effective mitigator of stress is peer support.

Peer Support Overview

What is peer support?

Peer support offers individuals affected by a major stress a chance to talk freely and share worries and pressure with someone who has had a similar experience or background (NCI, 2006). It is often used to help individuals dealing with mental health or substance use problems (SAMHSA, 2020), but has also been utilized in medical settings for support of physicians experiencing distress related to their work (Shapiro & Galowitz, 2016). The AMA offers a course on peer support programs for physicians, which is linked in this module’s Resource section.

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 in peer support programs 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 at least 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).

Social support is one very important and powerful stress management tool. It can mitigate some of the acute distress physicians encounter on a daily basis and even reduce the severity of later symptoms (Brooks et al., 2018; Maunder et al., 2004). When social support comes from a peer who understands at least part of what the individual has experienced, it is easier to feel understood, which helps make the support more effective (Shapiro & Galowitz, 2016).

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). Peer counselors 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).

Check on your own status first

As with helping in any crisis or stressful situation, it is important to check your own status first. How stable are you feeling? Consider how your mood has been recently and whether you are able to fulfill your responsibilities. In order to be fully present to help a peer in distress, you need to be feeling stable yourself. Ideally, you would be in a position to convey a sense of hope.

A Potential Application for Peer Support: The COVID-19 Pandemic

Pandemics can increase anxiety about the safety of self and others, reduce feelings of social connection due to safety precautions, add the stress of long work hours and high emotions, and bring feelings of frustration for any increase in factors that are out of your control (McMahon, 2016) further compounding a relatively high rate of burnout for healthcare workers even before the pandemic (Patel et al., 2018; Alexander et al., 2018). Two surveys of physicians several months after the pandemic started reveal the extent of the impact:

  • A survey of 1200 physicians, physician assistants, and nurse practitioners found 72% had more general anxiety than before the pandemic, and 66% were at least moderately concerned with being infected themselves (CHG Healthcare, 2020).
  • In a survey of 2373 U.S. physicians, stress from fear of exposure and perceived anxiety and depression were greatest for women, inpatient, early or mid-career, and critical care physicians (Linzer, 2020). Peer support can be helpful in situations like this, both during the crisis and afterward, to help with lingering effects.

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. Elicit your peer’s story about what is concerning them.
  3. Assess the impact on your peer.
  4. Provide an intervention that helps address what you learned in the first steps.

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

1. Make a Connection

Initial Connection

  1. Introduce yourself if needed. Explain your situation briefly, so your peer is aware of what you have in common.
    Example: I graduated in ‘09, too, but from UVA.
  2. Check on the timing and environment of your meeting. Extend hospitality
    Example: Is this an okay time to talk? Would you like to sit somewhere comfortable? Would you like some water?
  3. Offer statements of support, such as, “I’m here for you.” Describe the goals for your interaction being informal social support and not clinical.
  4. Provide reassurance of confidentiality, but remind your peer of limits to confidentiality if they or others are in danger of harm.

Tip

Consider meeting online if contagion is a concern. While mask-wearing is the norm for face-to-face meeting, video-chat offers the advantage of allowing you to see each other’s facial expressions. Another potential benefit is that some people express emotions more easily when meeting remotely.

2. Elicit Their Story

Ask your peer what is concerning them using open-ended questions (cannot be answered yes or no). 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 have a beneficial effect.

  • Encourage your peer to tell their story but 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.

Listening Skills

Listening skills that are often effective in peer support include using both active listening and reflective listening.

Active Listening

  • Face the other person directly or sit beside them if they seem overwhelmed.
  • Give your peer your full attention.
  • Pay attention to both the information they share and the feelings they display.
    • Listen for the meaning and emotions behind the words.
    • Look for non-verbal cues of distress and other feelings, such as tone, pitch, and pacing.
    • Check any conclusions you draw from these cues for accuracy, however.
  • Use body language that shows you are actively listening and recognize the emotion behind what is being said (Patel, 2019; WA, 2009).
    • Maintain an open posture with arms and legs uncrossed. Avoid leaning backward.
    • Maintain an appropriate distance.
    • Nod your head gently or use responsive facial expressions.
  • Provide verbal statements of acknowledgment, validation, and support.

Reflective Listening

  • Reflective listening is conveying your understanding of what the other person said by briefly paraphrasing in your own words the other person’s thoughts and feelings. Focus on what seems most important to them. Check with the other person for the accuracy of your understanding.
  • Some words that might help you get started are the following, but be careful in using them too often in the same way, or you’ll trigger a feeling of being in therapy, rather than support:

You: Sounds to me like…

You: So, in other words…

You: What you’re saying is…

Tip

Drop your voice at the end of a reflection, rather than raising it like a question.

Try Out Your Skills:

Listening for Emotional Charge

Reflective listening can be more powerful if you include a description of the emotional charge that your peer expresses.

Instructions: As an exercise in listening for emotions to reflect back, click on words in the following peer’s statement that seem emotionally charged:

Two possible reflections for this peer’s statement:

Here are two possible ways to use reflective listening with the peer’s story above, one that omits a reflection of the emotional content and one that includes reflection of the emotional content.

  1. Reflection that omits emotional content (less effective):
    You: You had a busy day with too many patients to keep up, and you had to choose who to help. 
  2. Reflection that includes emotional content (more effective):
    You: What a rough day! It not only exhausted you but also forced you to have to make choices that really got to you, and you doubted if you could continue and felt ready to quit. 

Even just naming an emotion that another person is feeling can feel validating to them. If you ignore your peer’s emotion, it can send the message either that it is too much to bear, or, at the other extreme, that you don’t think it’s worth getting upset about.

Try Out Your Skills:

Listening for Emotional Charge

Reflective listening can be more powerful if you include a description of the emotional charge that your peer expresses.

Instructions: As an exercise in listening for emotions to reflect back, think about which words in the following peer’s statement that seem emotionally charged.

Distressed Peer: “There was one day I was almost ready to quit. I ran from one patient to the next all day. We had two people code at the same time. It gets to you because you have to make a choice, you know. Halfway through the day I felt exhausted. I just thought, I can’t do this any more.”

Show Emotionally Charged Words

Two possible reflections for this peer’s statement:

Here are two possible ways to use reflective listening with the peer’s story above, one that omits a reflection of the emotional content and one that includes reflection of the emotional content.

  1. Reflection that omits emotional content (less effective):
    You: You had a busy day with too many patients to keep up, and you had to choose who to help. 
  2. Reflection that includes emotional content (more effective):
    You: What a rough day! It not only exhausted you but also forced you to have to make choices that really got to you, and you doubted if you could continue and felt ready to quit. 

Even just naming an emotion that another person is feeling can feel validating to them. If you ignore your peer’s emotion, it can send the message either that it is too much to bear, or, at the other extreme, that you don’t think it’s worth getting upset about.

Tip

The techniques for listening that were presented in this section can be effective if you can deliver them naturally. But remember, it is more important to be fully present and let them know that you are listening and care.

Express Empathy

The same empathy used in patient-centered care is important in providing peer support and involves sensing and understanding another’s emotions (Patel et al., 2019).

The skills described above for connecting with your peer and eliciting and then listening to their story, provide a structure for expressing empathy in effective ways. For many people, verbalizing empathy is a challenge even when it is felt. The following are statements of empathy that might be appropriate, depending upon the situation:

Example statements of empathy

3. Assess the Impact on Your Peer

Assess your peer’s needs informally, not clinically, to identify what distress they are experiencing, so that you can help them talk about it and feel supported. The assessment will determine what interventions they might need. Some interventions can be supplied within peer counseling. Some individuals may need recommendations for formal evaluation and possible treatment.

Ask Basic Questions

Ask several basic questions about their needs and functioning:

  • Are they safe?
  • Are there medical or health problems? Check on sleep and appetite.
  • Are basic needs being met? Physical, e.g., childcare, food, housing, sleep, and psychological, e.g., social support, mental health, spiritual needs
  • Are they able to function well enough to complete activities of daily living and meet their responsibilities?

Examples:

You: Are you safe? Feeling okay? Any health problems? How’s your sleep and appetite? Are your basic needs being met for food, clothing, shelter, childcare? Are you getting the support you need?

Affirmative answers to these questions are among the strongest indicators that your peer needs a professional evaluation.

Tips

Many of us avoid emotional content when it feels intense and skip right to problem-solving. Try taking a deep breath and making a small gesture, like a nod, to let your peer know you heard how intense it was for them. Silent acknowledgment can be a way of showing compassion.

Assess for Distress vs. Dysfunction:

  • The majority of individuals involved in a disaster or other major stressful event, 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 some 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. Further contact could be misconstrued as developing a therapeutic relationship, though.

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 is there dysfunction, and do they need more help currently?

Remember, your role is social support and not clinical, so if there is any doubt about your peer’s stability, mental health, or functioning, recommending a professional evaluation is indicated.

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 is indicated, for example, through their place of employment.

View more details:

Compare Distress vs. Dysfunction for Cognitive Effects of Stress

Compare Distress vs. Dysfunction for Emotional Effects of Stress

Compare Distress vs. Dysfunction for Behavioral Effects of Stress

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. For example, ask what they mean by terms, such as “depression.”
  6. Ask about any basic needs they did not mention.

Examples of How to Assess A Distressed Peer:

You: How has that affected you?

You: I want to understand what you mean when you say you’ve been depressed because people can mean different things when they say that.

You: What do you notice?

Test Your Skills So Far

Peer: This week was tough! We had a child come in after their birthday party and a pregnant woman, late term, both with COVID-19.”

Which of the following is most likely to engage this peer who is in distress and help them open up about their concerns?

You: Did you find it difficult?

You: You should try to take the weekend off!

You: Whew! You sure had some sad experiences in the clinic this week.

4. Provide Interventions

A compassionate response has been described as involving several steps, the first of which overlap with empathy: Recognizing the other person’s suffering and resonating with it (Cameron et al., 2015). Compassion also involves taking some movement toward addressing the suffering. Some of the interventions you can use to respond to a peer’s distress include the following:

♦ Let your peer vent. Allow them to express grief, loss. Spend time on it. Don’t rush to offer a solution.

Peer: It’s nothing you don’t already know about.

You: But I don’t know how it’s affecting you.

♦ Help the distressed peer go through their thoughts and feelings to find answers to their own problems.

You: What are your thoughts and feelings about it?

♦ Plant the seed of the importance of social support

You: Everyone who has been through something like this before says that staying connected socially is important. Keeping in touch with people who understand, people who can uplift and distract us, people we love, people who remind us what’s most important.

♦ Pave the way to getting further help if needed (unable to fulfill responsibilities, signs of mental health or medical problems related to the distress).

You: I want to leave you with a few numbers that you can call if you need further help. You may not need them, but I want to make sure you have them, just in case.

♦ If there is persistent distress, and the peer cannot function, that is, they have dysfunction, recommend that they obtain professional evaluation and support and facilitate the connection as needed.

You: I’m concerned about how long you’ve been feeling this way, that it’s getting in the way of being able to function sometimes, and that you’ve been trying to handle it all on your own. Some ongoing counseling, like through the hospital’s wellness center, might help you get back on track.

Quick Interventions to Try

Instructions: Read the dialogue of a peer trying to offer support to another. Can you name the intervention is being used?

Remember, use interventions that feel most natural for you.

Quick Interventions to Try

Instructions: Read the dialogue of a peer trying to offer support to another. Can you name the intervention is being used?

1. “What other way could you look at it?” Intervention type?

2. “I wouldn’t be surprised if there are times you feel down, have low energy, or feel like crying.” Intervention type?

3. “You mentioned that you have faith that science will come up with a vaccine.” Intervention type?

4. “What if you put that off for a day and slept on it, maybe talk it over with someone who’s opinion you respect, and make sure it’s what you really want, in the big picture.” Intervention type?

5. “With some of the things you’ve experienced, I’d be surprised if you didn’t have a good cry now and then. You are human. ” Intervention type?

6. “What would be most helpful right now?” Intervention type?

Remember, use interventions that feel most natural for you.

Tip

Avoid saying: “You should,” or even at first, “You could.” Try to help your peer to discover their own solutions.

Additional Interventions

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

♦ Review what your peer knows about stress management.

You: What kinds of stress management do you already know?

Peer: I know about the physiological effects of deep breathing, and does work when I remember to do it.

♦ Talk about the effectiveness of optimism. Sharing your own experience can be effective, if they are interested.

You: Would it be okay if I told you something that helped me in a situation like that?

Peer: Sure.

You: I reminded myself of all the times life surprised me with something good that I never expected and that many things I worried about never happened.

♦ Validate their concerns (Don’t trivialize them).

Peer: They are cutting funds for my program since income from elective surgery is down. Plans we worked on for a year are being put on hold indefinitely. I mean, I should be grateful I have my health, but it still hurts.

You: You lost a year’s worth of work. You can be grateful for your health, but losing the work you put into your program is still a loss.

♦ When a conversation becomes non-productive, paraphrase what your peer says, emphasizing just the part that will be helpful to redirect the conversation.

Peer: (Repeating talk about their anger at the administration for the fourth time. The administration has corrected the problem and apologized.) I get so angry thinking about how those in charge failed to get us the personal protection equipment we needed.

You: You want to be able to rely on the administration. It makes sense to want to feel safe as you move forward.

♦ Summarize the key thoughts, concerns, and plans your peer came up with, especially those with a strong emotional reaction. Then check with your peer to see if you left out anything important. (NCI, 2006)

You: So, the hardest parts right now are your fear of infecting your family and your exhaustion. Did I leave out anything?

Peer: There’s my fear of getting infected, myself, too.

You: Of course, that one was clearly important. We’ve tossed around some ideas for how you can reduce the stress or change some of these concerns. What would you like to focus on the most?

Peer: I appreciated your sharing your own story about overusing energy drinks. I think I need to break that habit myself because it’s not sustainable in the long run. And I want to make more time for some fun with my kids.

What about sharing your own experience?

Sharing your own stresses needs to be done in a way that it does not detract from the 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, so is commonly used in peer support led by recovered addicts, for example (SAMHSA, 2020). When done in the spirit of inspiring someone, it can be effective. 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. 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. Alternatively, ask if they would like ideas or suggestions.

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. For many physicians, the workplace has a list of such resources. Some individuals may not want to avail themselves of work-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 Advice and Resources tabs for this website.)

Follow-up

Experts in peer counseling warn that if the peer support relationship continues, it might be misconstrued as a clinical one (Everly & Lating, 2018). If the peer requests an ongoing relationship, also consider that it might be a sign that a clinical evaluation is needed.

That said, some experts in peer support recommend a brief follow-up check-in a few days later, especially in an acute crisis (Everly & Lating, 2018). It can help make sure that your original assessment was accurate or has not changed for the worse, and that your peer’s needs look like they are going to be met. In an acute crisis, particularly if the person was in shock at your initial contact, the person may become more aware of their needs a few days later.

Even if your peer does not need resources currently, at follow-up, make sure that your peer is aware of resources, such as how to access support groups, any institutional support, and mental health treatment that they may find they need later.

Poll: Compare Your Stress Experience with Your Peers

Consider the following poll asking about symptoms of burnout that have been reported by physicians in a variety of studies over the past 10 years (Jackson et al., 2016; Oreskovich et al., 2015; Mota et al., 2013; Bohman et al., 2017).

Preview:

Apply what you learned in an interactive scenario: Dr. Jeffrey T. (next page)

Summary

Support for a peer in acute distress involves the following steps:

  • Develop a rapport with your peer, which means connecting with them. This often involves finding common ground.
  • Provide social support for your peer, which is one of the most effective ways to mitigate acute distress. Clarify that you will not be doing therapy
  • Use open-ended questions to find out what is concerning your peer, that is, questions that cannot be answered with a simple “yes” or “no”.
  • Assess what is going on with the peer and the severity of their distress, including whether they are able to function.
  • Listening is one of the most important ways to help a peer in distress.
    • Listening should be reflective, which means paraphrasing what the other person says in your own words and is effective for helping people feel heard.
    • Listening should be active, which includes providing verbal statements of acknowledgment, validation, and support. Be fully present as you listen.
  • Provide interventions, which are actions you take to help lower your peer’s acute distress, based on what you learn during the assessment. These include:
    • Let your peer who is distressed vent.
    • Help them think about their thoughts and feelings and come up with solutions themselves.
    • Provide anticipatory guidance about what they might expect to experience in the future.
    • Ask what you can do to help.
    • Normalize their distress
    • Encourage social support and optimism.
    • Pave the way for them getting help when needed.
  • More interventions:
    • Provide reassurance. Instill hope by focusing on opportunities rather than loss.
    • Advise them to delay impulsive actions.
    • Review what your peer knows about stress management. Remind them about or teach deep breathing, avoiding energy drinks, etc.
    • Reframe your peer’s thoughts that are focused on the negative or that are stuck. For example: “What other way can you look at it?”.
    • Share your own experience, if your peer is interested in hearing it.
  • Provide resources including information on ways to get help in case your peer needs it currently or later.
  • Recommend further assistance as needed, if the peer is experiencing dysfunction in their lives in terms of mental health problems or inability to fulfill responsibilities, or feels the need for further supportive contacts.
  • Consider whether a follow-up check-in with your peer after a few days seems indicated. Particularly in an acute crisis, even if the individual seems stable currently, they may need help later. However, further connection can lead to confusion between peer support and a clinical relationship.

Interactive Summary

Peer support involves providing social support and resources for a peer in acute distress. The support is to help mitigate acute distress and not an ongoing or clinical relationship. Support for a peer in acute distress involves the following steps:

Resources

Resources for Peer Support

Resources for Personal Wellbeing/Resilience

  • Resources for Wellbeing in General:

Resources on Grief:

Resources on Finding Counseling

References

Back to Activity
Log In
Forgot Password?
Reset Password
Enter your email address or username and we'll send you instructions to reset your password.