One physician got in touch with Liz Lawrence, MD, FACP, after several patients died of COVID-19 on a single hospital shift. In another circumstance, a physician reached out and wanted to talk about feeling overwhelmed with professional commitments, working shifts, and handling Zoom calls while juggling child care.
“Just being asked to do the impossible,” said Dr. Lawrence, chief wellness officer at the University of New Mexico (UNM) School of Medicine in Albuquerque, who participates in the peer support program there. “I don't have the answers. But I can listen, and I can acknowledge, ‘Yes, that's an impossible situation. That's normal that you feel overwhelmed.’ Often having that opportunity to be heard is healing.”
The training and practice of medicine have always demanded a significant degree of stamina and resilience, considering the long hours and potentially life-and-death stakes involved. Even before the pandemic, medical groups including the American College of Physicians have been increasingly aware of the risk that physicians face from related mental health strain, potentially complicated by a reluctance to get help.
Along with worries that any mental health treatment may have to be disclosed on future licensing and other applications, physicians can be prone to skimping on self-care because of time, or at least a perceived lack of time, said Louis Snitkoff, MD, MACP, a retired general internist in Upstate New York and one of ACP's Well-being Champions, a program created in 2015 to foster wellness and professional satisfaction. (More information about ACP's well-being initiatives is available online.) The stigma against getting mental health care may be even greater among physicians than among the general public, Dr. Snitkoff said. “Just because we're not supposed to be sick—it's this culture of invincibility.”
In recent years, hospitals and other medical groups have begun to embrace peer support programs as more informal pathways for physicians to get help. While the specific design may vary, the underlying goal is to pair trained physicians with colleagues, preferably those with similar training and background, who have requested or agreed to the support.
Since COVID-19 emerged, physicians have been coping with the daily challenges of social distancing and the loss of a prepandemic lifestyle faced by all Americans, Dr. Snitkoff said.
“Now on top of that, they're working in an environment where there is a surge of serious and critically ill patients. They're being called upon to provide professional services that may be outside of their comfort zone just because the needs are so extreme,” he said. “And they're dealing with patient death at unprecedented levels.”
The need to ramp up peer support efforts became apparent following the April death by suicide of Lorna Breen, MD, a New York City emergency physician who had been treating COVID-19 patients, said Caroline Gomez-Di Cesare, MD, PhD, FACP, the Bassett Healthcare network director of well-being. The hospital system, based in Cooperstown, N.Y., has received funding from the New York State Health Foundation to build a peer support network for clinicians at Bassett and four other health systems in central New York State.*
“It really helped bring to the forefront the incredible stresses that clinicians, particularly physicians, were experiencing,” Dr. Gomez-Di Cesare said.
Culture of silence
Peer support programs will ideally counteract the sometimes engrained mindsets and work dynamics that can discourage physicians from seeking care, Dr. Gomez-Di Cesare said. As leaders of clinical teams, physicians have been trained to fix things and don't tend to admit vulnerability in any regard, she said.
“We have a culture of endurance and a culture of silence,” Dr. Gomez-Di Cesare said. “It's really an ethical imperative that we provide as supportive of communities as we can. And that we change this culture of endurance to one where we care for ourselves and we care for each other in order to best care for our patients.”
While the administrative burden for all physicians is extensive, it can be particularly so for primary care doctors given the documentation and insurer authorizations required for patient care coordination and specialist referrals, Dr. Snitkoff said. “So much of what physicians are experiencing in terms of work-related stress and moral injury is a product of the health care system,” he said.
The stakes of untreated mental symptoms are high, including burnout and far worse. One analysis, done before the pandemic and published Oct. 14, 2020, in JAMA Network Open, found that 52% of 1,305 internists and internal medicine trainees participating in an ACP Well-being Champion program reported symptoms of burnout. (See the related Q&A in this issue.) These symptoms were most frequently associated with lack of work control and documentation time pressures. Even more worrisome, the rate of suicide among physicians was found to be 44% higher than among the general population in a meta-analysis of studies worldwide published Dec. 12, 2019, in PLOS One.
But frequently, physicians who may need help don't get it, a pattern that begins in training. A meta-analysis published Dec. 6, 2016, in JAMA found that 27.2% of medical students screened positive for depression or depression symptoms. Among those who screened positive for depression, 15.7% sought psychiatric treatment.
In recent years, some medical groups have pushed to limit the scope of mental health or addiction treatment questions in applications for a medical license, with the Federation of State Medical Boards adopting a policy in 2018 that state medical boards should scrutinize whether such questions are necessary at all. If they are incorporated, the federation recommends that they be limited to current impairment and not diagnosis or prior treatment.
Still, states don't consistently follow this guidance, Dr. Lawrence said. “I've had students say things to me like, ‘I can't take Prozac. I'll never be allowed to practice.’ That really isn't true in most states and most places. But I can never really reassure them that it's not true at all.”
Thus, medical institutions have begun to launch peer support programs, most notably in the last several years, said Dr. Lawrence, who credits them with some inherent advantages. Since some states may consider these programs to fall under quality improvement or peer review initiatives, and the conversations are typically not documented, they may not be discoverable during litigation, she said.
Fellow physicians are also more likely to be available during weekend or evening hours to talk when more traditional services aren't typically open, Dr. Lawrence said. Plus, there's built-in trust, she said. “Who has a better understanding of what you're going through than a peer?”
Dr. Gomez-Di Cesare said that she had planned a limited peer support network prior to the emergence of COVID-19, but its scope was expanded with a second grant from the New York State Health Foundation after the pandemic began. As of November 2020, about 50 volunteers—nurses and other clinicians along with physicians—have been trained across the five participating health systems, she said.
Her program, which is adapted from one that Jo Shapiro, MD, developed at Boston's Brigham and Women's Hospital, involves building a network of trained peer supporters across a variety of clinical backgrounds. Then, when physicians reach out, or are referred to the network, they are matched up with a peer supporter who has similar clinical training, she said.
UNM School of Medicine, which launched a pilot peer support project in a few departments shortly before the pandemic started, has since revamped and broadened its approach to make it more proactive, with the hope of better reaching physicians, Dr. Lawrence said. In early November 2020, 38 faculty members, residents, and medical students participated in training, she said.
Kerri Palamara, MD, MACP, a Boston general internist and physician lead for ACP's coaching services, said that in mid-2020 she started gathering nearly 70 ACP Well-being Champions for monthly coaching calls to help them process and discuss ways to better assist physicians during the pandemic. Massachusetts General Hospital, where Dr. Palamara practices and directs the Center for Physician Well-being, is also developing a multifaceted support program for clinicians there, with access to everything from a buddy system to peer support to more formal group support and therapy, she said.
The buddy system will pair up clinicians so they can check in on each other on an ongoing basis, she said. The peer support program will be more formally structured with trained volunteers that will be available if the need arises, such as if a physician wanted to discuss a difficult or upsetting clinical experience.
“Then you could reach out and be connected with a peer supporter who will be with you during that and help you to process that,” Dr. Palamara said. “And then if you need additional resources, they can help connect you.”
Peer support efforts don't have to be highly structured to help strained physicians, said Diana McNeill, MD, MACP, who directs Duke AHEAD (Academy for Health Professions Education and Academic Development) at Duke University School of Medicine in Durham, N.C. As part of that program, she launched a series of video happy hours during the early months of the pandemic with various themes, including navigating Zoom calls and coping with virtual school at home. Icebreaker discussions led to more complex ones, from professional dilemmas to personal anxieties about contracting the virus, Dr. McNeill said: “The impact that COVID care has had on physicians may mandate the need for more peer support and more organized peer support.”
Will they come?
The UNM School of Medicine program had barely launched before the surge of COVID-19 patients arrived in spring 2020, Dr. Lawrence said. The program was thus unfamiliar and physicians coping with patient fatalities and draining shifts along with home logistics didn't reach out much for support, she said.
Dr. Lawrence and her colleagues decided to change up the program, starting at the end of 2020. Groups of physicians, such as those who have just wrapped up a stretch of COVID-19 care at the hospital, will now be contacted with offers of support at the same time. “Part of doing that blanket approach is that no one feels stigmatized,” she said.
When physicians respond that they are doing well, the peer supporter will still offer to send along some resources in case they're helpful later, Dr. Lawrence said. “It's a way of establishing a contact and a bridge that will hopefully lower barriers as we move forward.”
Dr. Gomez-Di Cesare is also working on ways to open the path for reluctant clinicians. A lot of time will be devoted to educating departmental leaders, as well as risk managers and employee assistance programs, about the support network to make it a proactive resource, she said. A continuing medical education series will focus on the impact of stress on clinicians and patients, along with the importance of self-care in the care of patients.
Health systems ignore the fallout from poor mental health at their financial peril, Dr. Snitkoff said: “There's a very strong business case for institutions to be attentive to this issue.” The cost to replace a physician who leaves or retires early can run a health system between $500,000 to $1 million in lost revenue, as well as recruiting and training costs, according to data published March 28, 2017, on the Health Affairs blog.
Peer support has limits, said Dr. Lawrence, stressing that volunteers are not there to provide counseling. “They are there to listen, to validate, to maybe refer to other resources,” she said. “It can be a starting point to enter into more formal resources.” The UNM program, she noted, has a psychiatrist for backup if there's a concern about a pressing need, such as a physician with suicidal ideation.
Dr. Lawrence also noted that physicians who volunteer may learn that supporting others provides an emotional payoff for them as well.
“I think one great strength about a peer-to-peer program is that in terms of burnout we find meaning and purpose in helping others,” said Dr. Lawrence, who has experienced that feeling herself. “It feels like a tremendous honor that a colleague would trust me enough to call.”