Tandi Wilkinson MD CCFP-EM (biography and disclosures) Disclosures: Received a UBC Dept of Family Practice Rural Scholar Grant to conduct research on the topic of peer support. Received a funding grant from Rural Coordination Center of BC (RCCbc) to support that project. Mitigating Potential Bias: No conflicts of interest. The article is consistent with current recommendations.
“I feel better when you are around. You smile and ask me how I’m doing”
Quote from my ER colleague at shift handover, March 2020.
What I did before
I am a rural family practitioner with a practice that is now limited to emergency medicine, always in single coverage emergency departments, and in many cases without any specialist backup in my community. I have always loved the work, but over time I began to notice that the difficult cases I encountered haunted me more and more. For instance, after the case of the young man in cardiac arrest that I couldn’t intubate or ventilate, I noticed I became more anxious in critical care situations. However, I carried on as usual, without even stopping to think about the best way to deal with what I was experiencing.
What changed my practice
In 2015 my world came crashing down. I developed disabling PTSD symptoms after being the sole physician provider in a medical disaster in a remote Arctic community. Although the situation was horrific, I also believe that it was the straw that broke the camel’s back, and the result of cumulative experiences over my career. I realized I would have to do things differently if I was going to continue to practice medicine.
I turned to the literature to understand my experience and learn what I might do to prevent it in my colleagues. The literature recognizes that peer support is highly desirable to physicians experiencing work difficulties, but that such support is commonly not available. Outside of the growing literature on formal peer support programs, I was in fact unable to find any literature on informal peer support (that which arises spontaneously, and outside of any formal structure). With the support of the UBC Department of Family Practice Rural Scholar Grant, I conducted a study examining effective peer support in rural Canadian physicians. (Spoiler alert: those who have had good peer support say it is essential to their career in medicine.)
What I learned is quite clear.
- Physicians want to talk to peers about work related stressors, because only peers understand the depth of responsibility we carry in our work.
- Peer support is easily available to us all, but we have to be intentional about creating it for ourselves, and for each other.
- Peer support requires us to be willing to be vulnerable. This is the key that opens the door.
- We can’t ever fully appreciate the value of the support we offer to our colleagues. One brief conversation can be literally lifesaving to the person who receives our support.
- Peer support often arises because a peer asks the question ‘How are you?’.
- We already do have the necessary skills to provide excellent peer support. It takes suspending judgement, generous listening, acknowledging, validating, normalizing, and re-framing. None of this will be hard because you will be speaking the truth as you see it.
- Providing peer support is easy when you realize it’s not your job to fix or rescue your colleague. Although they may be suffering, they aren’t broken. Your role is just to be with them right where they are.
- Providing peer support does not require us to be perfect. In my study, participants were aware of the limitations of their peer supporters as clinicians, and it was unimportant. What mattered was who those people were – friendly, open, approachable and trustworthy. It’s not what we do that matters as much as who we are.
- Diving into the world of giving and receiving peer support has deeply enriched my life. After every encounter I am left with a deeper and ongoing connection to my peer. When we meet again, it is not as doctors, but as human beings.
- One of the ways we transform difficult experiences is to use our experience to make the world a better place for someone else.
What I do now
Here is what I am doing now to ensure I, and my team, can manage through this unprecedented time at work.
- I have identified a group of colleagues who I can go to for peer support. I know them to be safe for me. Safety is essential. It requires someone who has the emotional capacity for the conversation, and the ability to put their own reactions in the parking lot. If the peer is triggered by your story, they can’t support you.
- I practice with those people now. It’s amazingly hard for me to ask for support. I needed to practice it several times in low risk conditions to become more comfortable with it. Talking about peer support isn’t enough. It needs to be practiced. I also need to practice providing support. Listening without fixing can be challenging.
- I ask for what I need. I wanted something uplifting in my day, so I recently created a virtual group called “Improving Our Beauty to Death Ratio”. In this case beauty stands for ‘that which in the presence of you feel awe’, and death is a metaphor for the scary, painful and difficult parts of our work. During times of more death, we need to ensure we have more beauty. I invited ten doctor friends to the group on the What’s App platform, and asked each of them to post daily on something that lifted them up in their day. It’s a small thing, but seeing what my friends are doing for self-care, and what moves them, and thinking about that for myself, is really enriching my life. I love the way the structure invites me to step into gratitude, and notice the beauty I have in my life right now.
- I ask people how they are doing. And in those conversations I am honest about my own experiences and difficulties, as a way of giving others permission to voice theirs.
- Peer support is about what we do, not about what’s going on in our heads. I now say what I think, whereas before I kept quiet. “I really appreciate you.” “You seem anxious, are you okay?” “How can I support you right now?”
- I use what I know about the value of relationships to build peer support. I know that providing physicians with the opportunity to connect with each other is helpful. We need that now more than ever. With that in mind, the Kootenay Boundary Divisions of Family Practice has created ‘The Antidote’. This is a daily, live, virtual gathering for all doctors, nurse practitioners, and midwives in our region. The twenty-minute drop-in sessions include a brief opportunity to connect with each other, some guided discussion on topics of great relevance right now (such as fear and uncertainty), a ten-minute guided meditation on the same theme, and the opportunity to stay on the call longer for further discussion. Although there are many online meditation offerings, the chance to gather as colleagues, and the real time meditation, I believe makes this program more impactful.
- I have to be a good friend to myself too. This is sometimes hard for us as caregivers. I am trying to practice self-care everyday. This is actually a very difficult thing for me to prioritize, but I know that if I can go outside, practice yoga (now online) or meditate for ten minutes, my day feels entirely different.
- I contribute what I have, instead of waiting to be perfect first. I might not be the best person for the job, but what if that person doesn’t come along? That thinking led my colleague and I to develop a physician wellness workshop. We certainly didn’t feel like we were qualified to do this, but we also didn’t see anyone else doing something we thought was vitally important and necessary. The ‘Transforming Our Work’ workshop is an opportunity to practice the skills we need to work differently, (vulnerability, generous listening, to ourselves, our bodies and our colleagues), and learn how to create a community of support with the people around us. This has been an amazing experience for me to be a part of, and I now have seventy new peer supporters.
Take care of your precious selves, and those around you. We can get through this together.
Additional reading
- The Voices in My Head (View) 23-minute video on peer support conversations.
- Eleven Things That Will Help You Hold Space for Someone: (View)
Resources
- Many of your regular group gatherings, such as the Problem Based Learning Groups, Journal Clubs, and weekly educational rounds can still happen online. It might surprise you to discover how pleasant it can be to connect this way.
- Consider joining REAL Groups ─ a unique small group learning experience that enables you to target timely and relevant topics with like-minded family physicians. (View )
- Or start a group around a theme that sounds like fun to you and see what happens.
- My personal favourite community building platform is Zoom, (zoom.us) because it’s simple to use and has the best quality audio and video of the ones I’ve tried. (Disclaimer- this is a completely evidence-free opinion!) Free subscriptions allow for group video conference calls of up to 45 minutes. Rural physicians in BC can also access a free professional level zoom account with more options (View on RCCbc website). (I don’t have stock in Zoom, although I wish I did.)
- Doctors of BC: Drop-in and share: COVID-19 Physician Peer Support Sessions
https://www.doctorsofbc.ca/news/covid-19-physician-peer-support-sessions
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Very helpful to read this right now! As a small community doc I have often identified isolation as an issue, now more than ever. I will be trying some of these options!
This information was very useful. This may be more difficult to set up in an urban setting
Very helpful! I find it important to have options being a rural health professional.
Thank you -this is very helpful in this time. Difficult to do in small groups/practises
I have been providing peer support to colleagues for many years. Our community was one of the first to have a physician wellness program in BC. Connecting and supporting one another has been the key to creating collegiality and breaking down the code of silence our medical training instills.
FH recently hosted a Forum for our Physician Wellness Champions and peer support was the workshop requested by the champions. The learnings you shared are exactly what we taught. I totally agree with your statements that physicians have the skills to do peer support, being openly vulnerability is important, and there is no perfect way to reach out to support one another: just reach out, show you care and listen, don’t fix. Modeling this behaviour is contagious.
I really appreciated the thoughts and ideas in this article. I am wondering if anyone knows of such a group in Vancouver or would be interested in starting a peer support group?
Very relevant as I have retired my office based medical practice only 6 weeks ago , just before Covid 19
I am planning to rest my body and mind
Plan an exercise yoga meditation schedule
My vulnerability: No solid peer group anymore
Used to be part of PBSG small group
As my burn out continued I felt less supported and could not reach out as the format was more formal. Also I was adding some cosmetic services. At present that is at a stop.
Peers comments suggestions very much appreciated
Thank you for writing this and highlighting it. I remember opening up to a colleague about how burned out I was, and him looking at me like I had three heads and just going on with his sentence. Safety is so pivotal, but unfortunately, those “safe” colleagues can sometimes feel few and far between.
Thank you. Timely and beautifully written.
After more than 20 years of clinical practice, I continue to learn daily. Peer support as above, and as in Sara’s “Voices in my Head” podcast, has been present on and off during my career. When present, I am more grounded and resilient. When absent, I am alone, small, fearful.
Doctor Leaders are beginning to recognise and respond to the need for peer support, self-compassion and community in order that we become our “grittiest” selves. Much more of this work is needed. I applaud the work of Connie (above) and other wellness champions across BC.
I encourage all to review this powerful submission, with a lens inward.
I have the absolute pleasure and honour to work with Tandi on some of these projects in the Kootenay Boundary.
Supporting each other always and through these difficult times is paramount in allowing physicians to be in their full potential. I am constantly in awe of my colleagues and truly want to see them thriving. As department head of family practice for 6 years, I felt like I was the maestro of a world class orchestra. I only hope that I can be a contribution in helping these amazing physicians move through this pandemic.
Good Article; I will wholeheartedly recommend Meditation (10-20 minutes/day, preferably in the morning, before one starts a busy day), Regular aerobic exercise, & attention to a healthy diet.
Meditation can be of various types; Vipassana Meditation is, apparently, very popular in the Vancouver & Victoria (I live in Edmonton), but even the Mindfulness Meditation & Qi – Gong Classes, Are easy to find in most areas (urban & rural).
Certainly peer-support groups are invaluable, but difficult to find in urban areas.
Thank you Tandi for sharing this with us! I am reminded that I am not alone. I appreciate you so much.
Thank you Dr Tandi for your honesty and bringing this to light so beautifully. I think we all need peer support that is honest and non-judgemental and non-threatening. To that end, I have found the PBSG program extremely valuable. What starts off as a group of learners usually becomes a group of peers who understand and support each other. Chosen wisely, group members will be that. For those who have never tried the PBSG program, I would highly recommend it.
Even you live remotely, you would be able to join a group virtually.
Let all of us always be kind and non-judgemental in our support for our peers.
Excellent, excellent info here. There needs to be a more concise version for a wider audience as many lay people could benefit from this info.
I strongly support this.
This should be part of all Medical Curriculums. It will prevent unnecessary suffering.
Thank you so much Dr. Tandi for an excellent article and the links enclosed. I too have experienced burnout and poor confidence in certain cases in Emerg and the OR, related to horrible past cases. I was afraid to reach out to my colleagues for support as it had not gone well when I’d done that previously. We work hard to listen effectively to patients but not as often with each other. The situation we now find ourselves in causes unprecedented stress to caregivers and patients alike, and your article could not be more timely. I plan to start giving better peer support immediately. Best wishes to you and thank you for all you do.
I forwarded this article to everyone I know (none of them doctors!).
This speaks volumes to me about what the world needs right now.
We ALL need to ask for help and we need to recognize this:
“It requires someone who has the emotional capacity for the conversation, and the ability to put their own reactions in the parking lot. If the peer is triggered by your story, they can’t support you.”
It is up to each individual to find these people for themselves. If we wait until we’re drowning in burnout and expect the first person we reach out to from desperation to be the one to “save us,” we are not in a good position to recognize that person may indeed not be able to support us and it has nothing to do with us.
So good. Please please please continue to share this.
I join all the other commenters in applauding Dr. T Wilkinson for a wonderful article, and lots of good advice. I am a retired female Family Doctor, and my son is an ER doctor. I think he could benefit from peer support, as he is juggling his busy front-line ER work during this pandemic, while functioning as a husband and father of two small children. He is clearly carrying his stress/distress, but unwilling to discuss it.
As I was reading the article, I suspected that this advice would be most welcomed by women. I notice that almost all the commenters are women. I want to remind everyone that men, on average, are not good at communicating feelings. Unfortunately, those same men are unlikely to take this information to heart. I wonder what proportion of the doctors participating with Dr. Wilkinson’s peer support group are male? How can anyone help them see the wisdom in these self care activities, before they reach their own “breaking point” &/or “burn out”?
Thank you so much for your vulnerability and for giving of yourself in this article. As a midwife diagnosed last year with C-PTSD triggered by workplace bullying and harassment, I have very little faith in finding safety in colleagues. This gives me hope that someday I will be able to practice again.
Thankyou for sharing this important information
To change my practice