Let's embed peer-support groups into the medical curriculum for all

The benefits of good peer support cannot be overstated, ranging from protecting wellbeing to improving reflective ability and providing psychological safety.^1–3 The NHS Staff and Learners’ Mental Wellbeing Commission report advocates establishing explicit peer support mechanisms and the use of peer support as part of the first line of psychological first aid.⁴ Peer-to-peer support methods are successful at providing wellbeing support, with a survey of 112 doctors showing 88% would potentially seek support from a physician colleague if needed, in contrast to only 48% who stated they would access mental health professional support.⁵

Junior doctors are the most likely of all medic groups to be at a high risk of burnout, with trainees being at particular risk of ‘feeling unsupported’.^6,7 Beyond supporting wellbeing, peer support is closely associated with improved resilience, the idea of ‘coping, adapting or thriving from adverse or challenging events.’^1,8 Reflecting together is also a key component of learning and training and is a General Medical Council (GMC) requirement.² Reflecting in an objective manner, as done in peer-support groups, is also beneficial to resilience, helping clinicians to avoid excessive self-criticism, which can impact on mental wellbeing and contribute to burnout.⁹

There is still a huge amount of stigma surrounding mental health, and concern from trainees about being perceived as a ‘failing’ or ‘problem’ trainee if they seek help.¹⁰ Practising as a doctor is unlike many other professions; it is more than just a job, it's part of a doctor's sense of self and identity: ‘Doctors do not become unwell and do not show their vulnerabilities.’¹¹ What is vital to understand is that medicine is challenging for everyone and we need to embed mechanisms to protect wellbeing into the medical culture from day 1. Group peer support allows everyone to develop a better understanding of the emotions and reactions of others in their team in order to normalise these emotional responses to their work and make headway in reversing the negative stigma.

The benefits of good wellbeing extend beyond the individual: the wellbeing of doctors is directly linked to the quality of patient care.¹² Better physician wellbeing was associated with improved patient satisfaction, improved treatment and even lower rates of hospital-acquired infections.^13,14 Moreover there is evidence that improving staff wellbeing has measurable financial advantages.¹⁵

We all strive for excellent healthcare, and this can usually only be achieved by a whole team of professionals. Teams work best when individuals feel psychologically safe.¹⁶ Students have described the psychological safety associated with peer-support groups; freeing them to learn in the present moment without being concerned about what others think of them.³ They feel psychologically safe because of the interpersonal connections, as well as understood and cared for as a person.³ These good interpersonal relationships are also linked to the perception that the organisation as a whole is supportive.¹⁷

The ‘Civility Saves Lives’ movement has brought to the forefront the knowledge that when someone is rude to a colleague it significantly reduces their cognitive ability and performance; research shows that the individual will consequently be 50% less willing to help others.^18,19 Bradley et al report that rudeness is more prevalent in certain specialties, namely radiology, general surgery, neurosurgery and cardiology.²⁰ Rudeness is more likely to happen when an individual is overworked or under-supported but, interestingly, not all high-intensity specialties have the same prevalence of rudeness.²⁰ The concept of the ‘hidden curriculum’ is particularly relevant in this domain, whereby entrenched tribalism and hierarchy in particular specialties may explain different departmental cultures and tolerance of this behaviour.^21,22 It is also interesting to note that different personality types are attracted to different specialties, and a complex interplay between these factors may help us understand the inter-specialty differences in behaviour.^20,21,23 We postulate that peer support encourages collaboration and support for colleagues, and the ability to understand how your behaviour influences others in the team, a key skill defined in Good medical practice.²⁴ Better peer support could lead to more civility, through increased insight into the emotional effects of these acts of incivility and through better staff wellbeing and coping strategies meaning better staff performance and ultimately better patient care.²⁵

During this period of mandated social distancing, there has never been a more important time to provide protected time and space for peer support. Trainees may rotate to a new job and may not have previously met the members of their new team. We already know that regular rotations with the continual changes of colleagues/teams and environments impacts on the ability to form relationships, resulting in poor morale and isolation from peer groups.⁴ This correlates with findings from the British Medical Association (BMA) survey that showed that junior doctors were at the highest risk of burnout.⁶ These issues are likely to be amplified in the current climate.

With this amount of evidence proving the importance of peer-support, why does peer support not appear universally in training curricula? The psychiatry and general practice vocational training schemes are ahead of the game by incorporating regular reflective groups focusing on the emotional aspects of interactions with patients as well as colleagues; other specialties should aim to achieve this too.^26,27 It perhaps feels logical that psychiatrists, as the profession specialising in the mental wellbeing of patients, are also proactive in looking after physician wellbeing. In addition, strong advocates like Prof Dame Clare Gerada with a background in general practice have also advanced the provision of wellbeing support.²⁸ It would be interesting to formally evaluate the use of peer support in these specialties but, with so many confounding factors, it would be difficult to establish.

Peer support can be delivered in many guises. The Tea & Empathy group (www.facebook.com/groups/1215686978446877/about) was created in 2016 and provides a peer-to-peer support network via Facebook to provide a listening ear and supportive environment for doctors. Other models have included 1:1 near-peer support with pairings of a junior and more senior doctor.²⁹ We have been using a model of group-based peer support whereby doctors have the opportunity to reflect with others in a similar position, with the distinct advantage of allowing peers to realise that their experiences and feelings are shared with many others.³⁰

If there is anything positive to come from this pandemic, perhaps it will be the heightened realisation of the importance of peer support. We recommend that regular peer-support reflective groups are provided online during protected time within the working week. While we have focused on trainees, we are aware of other groups who may find peer support particularly beneficial, namely specialty and associate specialist doctors (SAS), older doctors and overseas trained doctors, as we note these groups were identified via the BMA survey as experiencing particular difficulty in accessing support.⁶ Peer support is vital to integrate as a key support mechanism into the medical profession, through training and beyond.