Medicine is stressful. Few if any non-combat professions witness as much suffering and death as healthcare workers. Mental distress, burnout, addiction, and suicide are rife among physicians, and, it seems the numbers are getting worse. Recognizing the critical need for support and coping mechanisms, physician-led peer debriefing has emerged as a promising approach to alleviate the stress and emotional strain physicians face daily. When disaster strikes, it often evokes a deep human need to want to help each other. Medicine is no different. In the search for solutions, in this article, we consider peer-led support processes including peer-led debriefing as a possible way of reducing physician burnout.
One recent survey of resident and attending physicians, 79% experienced either a serious adverse patient event and/or a traumatic personal event within the preceding year. More than 80% of pediatric residents experienced at least one symptom or behavior associated with acute stress reaction or post-traumatic stress disorder. Inadequate time to reflect on such events contributes to burnout and the development of unhelpful coping mechanisms.
In 2019, 92% of surveyed residents agreed there was a need for debriefs to process the emotional impact of critical events, but only 11% had participated in one. Few physicians would engage with traditional mechanisms such as the employee assistance program (29%) and mental health professionals (48%). In contrast, physician colleagues were the most popular potential sources of support (88%).
Physicians have high innate resilience, and are arguably inoculated against stress to a large degree.... yet more than 80% of pediatric residents experienced at least one symptom or behavior associated with acute stress reaction or post-traumatic stress.
Debriefing originally was a psychological treatment intended to reduce the psychological morbidity that arises after exposure to trauma. It has been widely used in various high-stress professions, such as the military and aviation, to help people cope with the emotional impact of their work.
In the medical context, it involves physicians coming together in a safe, confidential environment to discuss their experiences, challenges, and emotional responses to patient care (Rosenzweig, 2002). Peer debriefing refers to people from the same profession providing support, but typically not as qualified mental health professionals.
As a psychiatric resident, I was taught that debriefing per se was bad. For many years, psychological debriefing was standard practice after a traumatic event. But then evidence started mounting that it could make things worse. Meta-analyses suggest that not only does debriefing not help but they can increase the risk of post-traumatic stress and other psychiatric disorders.
However, for physicians, the literature is more encouraging. Moreover, as physicians are most likely to seek out support from their colleagues and often underutilize established formal services, multiple professional organizations, including the American Academy of Pediatrics (AAP), endorse debriefing as a method of coping with distress.
In terms of training physicians to support each other, I enjoyed the article “Caring for Each Other: A Resident-Led Peer Debriefing Skills Workshop” by Grace M. Lee MD and colleagues. The Caring for Each Other Response team was available to debrief staff at the authors’ institution at all hours. Despite high resident awareness (74%) of this team, only 5% of residents had contacted them. So a training workshop was arranged.
Residents’ reported comfort in leading debriefs increased from 30% to 91%. The likelihood of leading a debrief increased from 51% to 91%. Ninety-five percent agreed that formal training in debriefing is beneficial.
Govindan and colleagues (2019) described a successful 2-hour training workshop to provide senior residents with the knowledge and skills to lead debriefing sessions within their teams.
What this doesn’t tell us is the efficacy and safety of debriefing in this population. Arguably, medical residents are exposed to different (lower level) traumas than those in the trials where PTSD increased. Peer-led debriefing is different than psychologist-to-patient debriefing. Physicians have high innate resilience, and are arguably inoculated against stress to a large degree. It’s likely that there are other differences, too.
Overall, physicians appear to appreciate these types of intervention. Whether such interventions actually reduce psychological morbidity or enhance resilience further is in need of evaluation.
1. Emotional catharsis: Peer debriefing allows physicians to express their emotions and experiences in a non-judgmental space. This emotional release can be profoundly cathartic, reducing the emotional burden and stress associated with difficult patient cases.
2. Enhanced resilience: Sharing experiences and coping strategies with peers can build emotional resilience. When physicians see how their colleagues handle similar challenges, they can adapt and develop their own strategies for resilience.
3. Improved coping skills: Peer debriefing provides an opportunity for physicians to learn from one another. They can discuss coping mechanisms and stress management techniques that have proven effective in their experiences (Reivich & Shatté, 2002)
4. Reduced isolation: Medicine can be a lonely profession, with physicians often feeling isolated due to the nature of their work. Peer debriefing creates a sense of community, reminding physicians that they are not alone in their struggles (Shanafelt & Noseworthy, 2017).
5. Prevention of burnout: By addressing stressors in real-time and collectively finding ways to manage them, peer debriefing can act as a preventative measure against burnout (Dyrbye et al., 2016).
Entirely speculatively, as a trained psychiatrist, I would suggest that by reducing distress, sharing the burden, realizing that we are not alone and bad things happen to lots of people including doctors, the effect is reduced arousal and stress hormone levels. Debriefs may provide reassurance, reaffirm competence, and facilitate a sense of community. Acute support after an event can reduce sleep disruption and rumination, both of which can increase the chances of a traumatic response.
On-the-job mental health support should be available 24/7 for people who are witnessing death and suffering all day long" - Pamela Wible MD
While debriefing led by our fellow physicians may play a role in reducing burnout, we echo Dr Pamela Wible’s comment that “on-the-job mental health support should be available 24/7 for people who are witnessing death and suffering all day long.”
Indeed, peer-led debriefing can only be one piece of the puzzle in the physician well-being ecosystem. We hope that the evidence evolves, with urgency, to elaborate whether this is a worthy intervention to apply at scale for everyone’s benefit.
One attendee recently said “Physicians Anonymous literally saved my life”.
Peer-led support groups run by Physicians Anonymous are facilitated by volunteer physicians and therapists. While we do not run formal debriefing processes, physicians will often talk about traumatic events from their working lives. We do not record our meetings or hassle attendees with surveys, but our qualitative feedback is enormously positive.
One attendee recently said “Physicians Anonymous literally saved my life”.
If you or someone you know could benefit from our FREE support, please check out: https://physiciansanonymous.org/anonymous-meetings/
