Episode 29 - Jo Shapiro Pt. 2 - Implementing Peer Support

As difficult working conditions continue to negatively impact the well-being of healthcare workers, the need for peer support has become clear. In part 2 of her discussion with Medplace, Dr. Shapiro explains the signs of an effect support system and how healthcare culture sometimes works against providers.

  • 00:10:11 - 05:10:11

    Adrianne Fugett 00:02

    Welcome to Reimagining Healthcare with Medplace: A New Dialogue with Risk and Patient Safety Leaders. If you find value in today's podcast, please share and subscribe. If you're interested in being a guest speaker with Medplace, you can reach us at speakers@medplace.com. Also check out our blog for related content for videos and articles. Last time, we were joined by Dr. Mark Greenawald, where we discussed physician well-being through his technology platform, PeerRxMed program. Today I'm joined by Dr. Jo Shapiro. She is an associate professor of Otolaryngology (head neck surgery for my non medical listeners) at Harvard Medical School. She's also a leader in the effort for peer support, which I've had an opportunity to talk with you a little bit about that Dr. Shapiro, I'm very passionate about this. And I am also, as you know, very concerned about the mental health well-being of our health care providers. So I'm really excited to have you here today. Welcome.


    Jo Shapiro 01:03

    Thank you so much for having me.


    Adrianne Fugett 01:05

    Great. You know, it looks like I've got a couple of questions. And like I said, I hope we get to all of them. But you know, knowing you and I how I've met you already, we may go off tangent with that. That's okay. But with over 20 years experience that you've got in hospital leadership, as well as at Harvard Medical School, you've been a driving force in peer support for physicians. So can you tell us a little bit about your career? And what led you to understand the importance of this topic and what it means for physicians and really a little bit about what you and I talked about previously, how that translates to health care for those of us that are consumers?


    Jo Shapiro 01:51

    Well, thanks for asking. I do want to make sure I I'm always very inclusive about this being important for physicians for sure. And not just physicians that those of us providing health care, this, these kinds of issues affect everybody. So just want to make sure, although sometimes the studies are done about physicians, and we certainly are definitely in need of support and care as our colleagues in the team. Yeah, so I'm a surgeon and I was I practice clinical medicine surgery for over 35 years. And I have the honor of having a fair amount of different kinds of leadership positions. It previously including being Division Chief for at Brigham and Women's Hospital in otolaryngology, but also one of the leaders in graduate medical education for which is residency and fellowship for, for all of MassGeneral and Brigham hospitals and affiliates. And at being a practicing clinician, in those positions, I just saw so much suffering. And when I say suffering, I mean actually suffering on the part of the people who are doing the work, taking care of patients, training others to do so researching, just a lot of suffering. And I thought what, we've not as a profession, paid almost any attention to that. And if we're suffering, first of all, it makes our careers not sustainable, but also it's going to translate into our giving, not as good care as we could to our patients. And I really want it to be a part of at a at an organizational level of actually doing things that would improve the well-being of those of us in healthcare.


    Adrianne Fugett 03:47

    Wow. You know, I had chatted with you briefly prior to this podcast. And one thing that I noticed very early in my career as a medical ICU nurse, and I'm talking early 90s, right? I noticed some very concerning lack of well-being for lack of a better word, amongst physicians and nurses, especially, and I thought to myself knew in my career, I thought, This isn't sustainable. And back then there was not a lot of talk about peer support for nurses or physicians or really, anyone in health care. I mean, you just, you did what you did and did what you were told and you know, you've got all of these things. How do you think peer support has changed with the COVID pandemic, as well as post COVID pandemic? Where are we now in regards to peer support and hospitals and physicians and nurses really even understanding what this is and do we need to implement it within our hospital? Like, can you tell us where you think we are and where we need to be maybe even?


    Jo Shapiro 04:58

    Yes, I think it's Great question. And I would step back and say there's peer support is a well-being program, essentially a well-being intervention away, to improve well-being. But of course, it's not the only one. So these things have obviously grown in parallel. And I think as you know, were from our past years in mind that we certainly did, this wasn't in anyone's consciousness that there was an issue of our well-being. So I think that that had to happen first, in some ways for people to wake up and say, this is a problem. And to your point, we grew up in a culture that did not think that our needs were worth meeting. And I kind of bought that too. I mean, I think we I drank the Kool Aid, because we thought, well, we're in a healing profession, and we're supposed to be altruistic. And that means always putting other people's needs above our own. Which in the moment, of course, yes, that, of course we do. Right, our patients come first, right? We're our families it for sure. But always, never, ever, ever, processing our own emotions, and also recognizing our own our own humanity. And that because we are human, and because we're so committed, and caring, and compassionate, we are going to have suffering, we see suffering, and things go wrong, and there's lots of stressors. And so there wasn't a consciousness that actually our suffering on attended to might translate into suffering of the very things that we want to have happen, which is great care, great education, etc. And so I think there, there needed to be, and this happened for me in parallel was when I proposed starting the Center for professionalism and peer support. In 2008, when I wanted to do it at the Brigham and Women's Hospital, which is where I was also working clinically, is let's think of some multiple efforts to support well-being one of which is peer support. So now to your specific question about, so where are we at, and I think we would recognize that we're, we're better we're down the road a bit from the wellbeing lack of any thought that it was important to, I think there's so much data now by some great researchers who have shown this, this is a thing, it's quite prevalent, and it's devastating in many ways, and it can lead to very devastating consequences. So I think that's been incredibly helpful. And as you know, there's been a sea change of people saying, oh, gosh, we do have a problem. So then it comes to Alright, how do we solve what in what ways can we address the problem, I don't think it's a quick solution. Nor do I think it's a solution that we're used to, like, I'll take out your bankers and you won't have any swallowing problems anymore. This is not that kind of problem. So many, many people have been working on different wellbeing efforts, and they're all They're unique and different and interesting in their they, they, they, they deal with different aspects of, of things that drive burnout. And on the other side of the coin drain wellbeing. So peer support it when it when we first thought of it, it was incredibly countercultural, incredibly, because for the reasons you say, we were taught, first of all, we shouldn't be suffering anyway. So why would you need support. So that's one. And the second is even if you're suffering, you really need to walk it off, you really just need to deal with it yourself. And we have a big culture in medicine, the cult, a culture of silence, you aren't supposed to have any mental health issues, no less physical ones. And you certainly weren't supposed to have any sort of work related pain, from the things that happen at work in medicine. So I think they're we, that's when we started peer support, we were very much in that culture. And the other part of that culture that I think was so I was gonna say evil. It extreme, but really, just so counterproductive was this idea that any support any self care in any community or organizational support was weak, a sign of weakness needing that was a sign of weakness. And so you know, the last thing we want in our profession is to look weak, like we should be able to tolerate this suffering. So I think people get that, that's just so counterproductive and understand, at least intellectually, that self care is not selfish. That said, we're still in that culture to some degree. It's not like we had a memo. I say this, when I do give talks about peer support. You can't change the culture by saying, Oh, we don't do that anymore. Like self care is no longer selfish, right? Culture change happens. It can happen in big leaps. But it doesn't happen by telling people which this kind of culture is dysfunctional. I mean, that's part of it. But then what are you going to substitute it with? So I think we have to recognize an answer to your question, that we still have a culture of where we equate You know, strength with with lack of vulnerability. And fact, while we really know, and there are lots of people write beautifully about this, that vulnerability is strength, we're still in a culture that doesn't really believe that. So there's still stigma to needing and wanting and accessing help. Okay, that said, I think the stigma is getting better. I think also, the structural barriers to getting help are, are being lifted little by little by little, then you have all of this background. And we started peer support, at least when I was at the Brigham, and then helped others have helped over 100 organizations start their own peer support programs. It plenty of that was done before the pandemic, so we were making progress, right, then you have the pandemic. And you know, the first thing that happened is all attention goes to patients with COVID, basically, as it should, right. But a lot of people for now written about the fallout for healthcare professionals, including a colleague of mine, and I wrote a piece for the New England Journal about this is going to have a huge effect. And so what are we going to do about it? How are we going to help decrease the what we thought would happen, which there's a lot more mental health issues and burnout issues, which are not necessarily related to mental health? And so I think so we have that so many people's and some people actually, actually were motivated during the pandemic to say, now we really need peer support, which was true, but others were like, we can't even have to, but I think we're coming out of it, people realize, like, Okay, now we can't, we've got it. Now we have health care providers who are absolutely burnt out, from all the reasons they were before. And now you add all the suffering and all the what's been expected of health care providers, etc. And it is pretty, it's pretty awful to see. So I think what we are in now is people realizing, we've got to pay attention to taking care of each other. And the reason peer support, the reason we started peer support, in addition to being supportive of professional mental health resources, right, that's really important, in addition to looking at workflow issues, all those things that many brilliant people are working on, those are all important. And this came out of a study we did. We also knew that in the face of especially some of the acute stressors that we experience, like errors, like patient aggression, like being named in litigation, and then the chronic sort of sub acute stressors like COVID racism, harassment, all the other there's lots of other things that we face, that we need, the, with the stigma, of getting help, that we needed to structure a program that made getting help easy. And this our study showed that, in addition to that, there were barriers to seeking help, that what, and this happened to be a physician study with physicians wanted after an acute event, like an error was they wanted help from a peer, a physician colleague, even though you know, we have great mental health practitioners. So I think that's where we that was the genesis of actually establishing a program that says, Let's make, let's make this support, first of all, the kind of support that the studies show that healthcare providers want. That is, I don't need a behavioral health person necessarily, in this moment. I need someone who's been there who gets it. Oh, my gosh, I know exactly. Yes, this is really painful, and help. And that will help the person navigate that stress, strategize and hopefully come through it with some wisdom and growth versus being crushed by it. So that's the genesis and I think from I don't I don't think we have a direct study to answer that your question, but I think we are at the place where people are seeing that there's such a need for various types of support, that there's even increasing openness to, to doing this. So I think we're better off. But it's hard to measure that.


    Adrianne Fugett 14:09

    That yeah, true change. Yeah, it that's good to hear, though, that we are you know, even if it's anecdotal, because I will tell you some of the nursing research that talks about violence in the workforce and just bad work environments, that it does affect patient care. So Right. So there's no reason for us to assume that the burnout and everything that's happening with physicians as well can affect patient care. And that's important for all of us as healthcare consumers to understand, look, this is this is a collaborative collective effort, if you will, to understand that just being more open. You mentioned about there's still some stigma with people being able to show vulnerability but we are getting better as a society but just the overall arching Being of the importance of being able to be in a safe space where you can chat with a colleague like look, this is really stressing me out. I think that's important. Because as you said, then you're not crushed by the events that are going on around you which burnout, right, you're leaving the profession, you're looking for something non clinical, and then who's gonna be left to take care of you and I and our family and friends and all of that. I mean, it's hugely important.


    Jo Shapiro 15:27

    Yes, and I think you raise a really important point, which is when we were first thinking about well-being of physicians and other health care providers, we felt a little awkward about it, because we were like are people going to just think we're whining? And we were very privileged? There's no question about it. I mean, I think being in healthcare is just an incredible privilege. Because we are healers, which I just think is like one of the most beautiful things to be able to, to be in a position to do. And so we were really worried. I think when we thought about, well, how's this going to seem to, to our patients to society, are they going to be like, Oh, my gosh, I can't believe these people are whining. And I think you know, all you have to do is look at, look at the data to say that these things that are hurting us, and that are causing our suffering, as healthcare providers are very real, they're very intense, right? There, unlike what most other professions have to deal with. And with the pandemic, and with the shortage of with people leaving the profession, etc, but with a shortage of resources, etc, we have a bit we have a problem here. And that shortage of resources and personnel, etc, is then causing further burnout, because of the stress it puts on those who are doing the work. And this is, I mean, I think, I hope that society sees this as incredibly important. And really, that this is something that we all need to think about. Because we can't lose our workforce. No, we can that's not going to work for anybody. And so this is a, it's, I don't hope I'm not overstating, but it does feel a little bit like an existential threat to the healthcare workforce, if we aren't better about addressing these stressors. Yeah, I'm going to take a pause. But I did want to say something is, I think organizations also have to move on from this idea that we're supposed to solve the problem individually, that we should be dealing with this, oh, yes, you should just individual resilience why don't you go and once you go, and do go take a run or meditate, etcetera, all these things are really good these individual resilient training, but what about the organization, first of all, providing actual support, like peer support, but also what about the organization, stopping doing the things that are harming us with this increased production pressure, and decrease resources, it's like we were, there's only so much we can do without either burning out or also giving unsafe care. And I think organizations have to really wake up and say, we have responsibility for creating safe work environments, they're safer us as the providers of the care, and therefore safe for patients. And that's really key. And I don't, I don't want anyone to take away thinking peer support is just like, hey, you all solve it yourself? It's like, no, no, this is you said, it's a collaborative effort. And society probably too has to be part of it is what can we do to work towards improving this?


    Adrianne Fugett 18:43

    You know, that's really interesting, because I do think that pulling in administration, obviously to get buy in and just educating them about the importance of what peer support programs look like. Can you talk about a little bit for the audience? What a peer support program looks like and how it should work? That might be a really nice kind of segue into getting buy in from administration?


    Jo Shapiro 19:13

    I, I'd love to so I think of support is a spectrum, right? There's lots of ways we can support healthcare providers. So one is that you we've all had experience doing which is informal support, you check in with somebody, Hey, how's it going? I heard you had a rough day yesterday, or, gosh, it's been really stressful this past week, as you know, as an ICU nurse, and some sometimes you're just seeing really hard really awful things. You know, just patient outcomes because of the way diseases progress. So, informal peer support is wonderful, but it's not good enough for in some situations, it's not enough for some people. It's not meant to, you're not really providing a way for someone to really unpack what's going on or if they're really traumatized. So it's good, but then there's what would I call formal peer support, which is what I help organizations do, which is set up an actual program. So what makes this different. And that is the support first of all is done by a colleague, not a behavioral health person, right. So it could be a surgeon like I am, it could be somebody who is trained to be able to do this. And it requires some training, because it's not something we do we're used to fixing people's problems you bring a problem, I will fix it as a surgeon, but this is not fixing your colleague, it's helping them navigate this, the stressors, and access their own ways of coping, etc, but helping them in a in a, in a way that I think we can be trained to do, and so I fair disclosures, I do the training. So, I'm an educator, I think education is really helpful. So that's formal peer support. And the other job of a peer supporter is to de stigmatize and facilitate referral for further along on that spectrum, further support in the form of professional help, whether that be coaching, or behavioral health whatever it is, because some people, formal peer support will be enough, but others will need and want more. And yet, as we spoke about, there's barriers to accessing that. So what pure formal peer support does is it helps people if they want that support, get it and get it easily. And that so that's really sort of a picture of, of what it is. Interestingly, if you look at lots of initiatives that are needed to support wellbeing, peer support is, it's not really costly, it's really not a big expensive program. There are certainly well-being programs that are expensive and need those resources. So that's all good. This is just not one of those. And we have data to show that it's a something that people want we have done some studies that said, this is one of the factors that actually helps people with some of these work, workplace stressors. So one of the ways of working with leaders in health care is to show them one is the need. And there's so much need, and that there's so much data about the need, which is I'll give you one example, if you take a specific stressor, like making a medical error, that's harm to patient, which is not the most frequent thing that happens to any of us, thank goodness in our careers, but it does happen to very much everybody. Yep. The change if you've made a medical error, and this happens to be physician study, although I did also study with physicians and nurses, so just take that it's not just about physicians, there is a there's a significant emotional fallout from that, including, it's an independent predictor of both burnout and depression, having made a medical error. In addition, we know from a good study, that it's a risk factor for suicide, increased suicidal ideation. So those are pretty dramatic, bad things that can happen. And remembering that if you're burnt out, so there's a higher chance of becoming burnt out, if you made an error, you have a hot just being burnt out period, you have a higher chance to make a medical error plus just being burned out period from whatever cause is associated with a poor patient care on lots of domains. So I think for leadership for them to resource something they should know, what's the need, and the need is clear, right? And the data shows that. And then what's a program that that is called for based on the data. And this is an example of a program, it's not the only program it's a program, but it but I think to be fair leaders do have resource constraints. And so you can't just say we want this right, I would like to be able to trust me, but you know, you have to provide data, if you will, of you know, why it's necessary. So a lot of what I do is help organizations make the case to their leadership of like, we got to do this as one program. I mean, it's not going to solve all problems and figure out how to fit it in. Yeah, that's right. And it's very doable. It's, it's it's not it's really not that complicated. The other unique thing, for those of you who are listening who haven't heard of this about peer support is that you want to make the support. If someone says, oh, gosh, I'm suffering and I need help, it's got to be very easy for them to access this support, right? So they have to have a number to call, it's got to be easy, got to be confidential, etc. That's not enough. What you also need is you need to proactively offer peer support to people who you know, have been through an event, not whether they're stressed or not, you don't know them, necessarily whether it's stress, but instead of waiting for, for healthcare providers to exhibit signs of distress, we, with peer support, they will get a call from a peer supporter saying We heard there was an event or we heard there's you know, this week was very tough and we I'm offering you peer support, because we have this program because I've been there. And I know how hard it can be. And sometimes it's helpful to talk to a colleague would you like to do that? It is not forcing anybody, nobody should ever be forced to get any support or talk about something they've been through. But it see how easy I'm making it and destigmatizing it, hey, I'm reaching out to you, not because you're a big loser. But because this is what we now do. Of course, we reach out right and think of just letting you go and deal with this on your own, which is what we have done forever. It Yeah,


    Adrianne Fugett 25:33

    it becomes just the standard response that we give. You know, that's really interesting, because I was going to ask you, you brought up a really good point that as nurses and physicians, we end even in our personal lives, right, we want to fix everything, it's hard for us to be active listeners, because we're always wanting to fix it. So I like that methodology that you're proactive based on an event in the hospital or what have you that you're, you're reaching out that helping hand taking away that feeling that for a provider to just say, Should I call? Should I and you're just have that set up? You know, is there do you work with hospitals to leverage technology in? I mean, how do you do do it via email? Do they log into us? I mean, I guess it just depends on what the organization wants, right?


    Jo Shapiro 26:27

    Yeah, no, I mean, I think probably going forward, there probably are very creative ways to make this work to expand these programs. But the way we've done it for the past a good decade and a half with all these other organizations is usually the reach out would be let's via reaching out to you, I would email you, and in the subject line, I'd put touch base, and I'd say, hi, Adrian, I'm reaching out. As a peer supporter, please give me a call when you get a chance. So then you call him because I don't think explaining this on email is really going to do it. It's too nuanced. So yeah, call me and I say what I just said to you earlier, which is we have this, I don't know, if you know, this, we have a peer support program, etcetera. And so I'm destigmatizing it and I'm just making it routine and, and explaining it to you verbally. And then if you say I say would you like that? And if you say you know what? I'm good. Thanks anyway. So that's fine. Is it okay? If I send you a list of of other resources. So if for whatever reason, you or any of your colleagues says what, I'm kind of stressed about something, there are resources that you could have, and you can reach out to these people. Or if you'd like, you can tell me, you'd like someone to reach out to you or a colleague, I can make that happen, if that's what you know, if you'd prefer. Sure. Thank you so much, Jo, that sounds great. If they say yes, I would like this, then you figure out a time at of mutual convenience. And we have been using visual, remote technology like this teams or zoom or what have you, for peer support for years. And before that people would we would do by phone sometimes or in person it works. It works any of those ways. So in that way, we're leveraging that technology. I think there, I have been thinking that there should be also even better ways to spread the the support so I'm thinking about how to do that. But it's it does work pretty well. I think the biggest problem is how do you get? How do the people who run the peer support program get noticed that something has happened or that there's been significant type of stress. And that can be a hard connection to build. When I was at the Brigham, we had a really great relationship with patient safety, and risk management who heard about some of these big events, and then also the, the leaders that you know, the chiefs or the chairs, who would be like, oh, there was a patient aggression or something. And there was lots of word of mouth. So we would hear about a lot of things. But that takes a while to build those relationships. So that that's an area for improvement.


    Adrianne Fugett 28:59

    Yeah, creating a workflow. You know, I we're getting close to our time. And I tell you, I could talk to you about this all day long. And I really wish I you know, in listening to your conversation, I wish back in the early day, which I'm sure you know, looking back, you do, too. I wish we had something like this for me. I mean, like you said, working in under the conditions that we did, without really having outlets or feeling comfortable or like it was okay to talk about the stress of what you're going through as a nurse or a physician. I mean, this is fabulous work. I just can't tell you how much I am impressed. And thank you for your time. And if people are interested in learning more about peer support, can they find you on LinkedIn? Yeah, absolutely. Yes, for sure. Okay. All right, because I have a feeling that some people are going to want to connect with you and I just want to thank you again, for your time. And for the listeners. Thank you for listening. A new day dialogue with risk and patient safety leaders podcast. Again, if you found today's talk valuable, please share it and subscribe, subscribe. And if you'd like to participate as a guest, as I mentioned earlier in the podcast, you can reach us at speakers at Medplace.com Thank you so much and thank you Dr. Shapiro.


    Jo Shapiro 30:18

    Thank you for having me.

What do healthcare providers need to avoid a mental health crisis?

62.8% of physicians report feelings of burnout, and 1-in-5 say they are making plans to leave their current practice within 2 years, according to Healthcare IT. Other types of healthcare providers, like nurses, show similar signs of exhaustion. In this podcast episode, Dr. Jo Shapiro, the Associate Professor of Otolaryngology at Harvard Medical School, dives into the intricacies of implementing peer support.

Dr. Shapiro explains several obstacles to peer support and potential ways to overcome them. Healthcare culture, while in many ways encourages great care, can prevent providers from getting the care they need. Also, she highlights how to persuade healthcare organizations to implement peer support using data, and shares the inexpensive yet effective ways to support healthcare workers.


Guest - Dr. Jo Shapiro, MD

Associate Professor of Otolaryngology at Harvard Medical School

Dr. Shapiro is an associate professor of otolaryngology-head and neck surgery at Harvard Medical School. She is senior faculty for the Center for Medical Simulation in Boston and a consultant for the Massachusetts General Hospital Department of Anesthesia, Pain and Critical Care. In 2008, she founded the Brigham and Women’s Hospital Center for Professionalism and Peer Support where she served as the director for over 10 years. 

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