AMA STEPS Forward® podcast
Creating a Peer Support Program
Dec 5, 2023
Featured topic and speakers
In this episode of the AMA STEPS Forward® podcast, Jill Jin, MD, MPH, speaks with Angela Chaudhari, MD, a practicing obstetrician-gynecologist, about the Scholars of Wellness peer support pilot program she created for the OB-GYN department at Northwestern Medicine that was eventually implemented hospital-wide.
To learn more, check out the AMA STEPS Forward® Scholars of Wellness toolkit.
Speaker
- Angela Chaudhari, MD, obstetrician-gynecologist, Northwestern Medicine
Host
- Jill Jin, MD, MPH, senior physician advisor, AMA
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Transcript
Speaker: Hello and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real world solutions to the challenges that practices are confronting today, solutions that help put the joy back into medicine. AMA STEPS Forward® program is open access and free to all at stepsforward.org.
Dr. Jin: Hi, everyone. This is Jill Jin. I'm a physician advisor here at the AMA and today I am speaking to Dr. Angela Chaudhari, who is an obstetrician/gynecologist at Northwestern Medicine in Chicago, and also a physician leader and innovator. She developed the topic of our discussion today, which is the peer support program, first within the OB/GYN department at Northwestern, which was then scaled up to the rest of the organization. We will definitely get into all that, but first Angela, welcome and thank you so much for joining me today.
Dr. Chaudhari: Thank you so much for having me, Jill. It's such a pleasure speaking with you.
Dr. Jin: Do you want to give our listeners a quick introduction of yourself, your background and current position?
Dr. Chaudhari: Sure. My name is Dr. Angela Chaudhari. I'm an associate professor here at Northwestern University's Feinberg School of Medicine in the Department of Obstetrics and Gynecology. My clinical focus is in minimally invasive gynecologic surgery, and I care for people of all genders in that role. I am lucky to serve as the chief of gynecology and gynecologic surgery here at Northwestern Medicine, where I get to be a large part of our quality and safety plans. And I serve as the director of our P2P Network, which is our Physician Peer Support Network here at Northwestern Memorial Hospital, which we've just scaled, as you mentioned, to the rest of our Northwestern Medicine organization.
Dr. Jin: So yes, this has been quite the project that you've undertaken and that's why we're so excited to have the chance to talk to you today. Let's start from the beginning. Your initial project, it was part of Northwestern's Scholars of Wellness project. And we did have a previous podcast with Dr. Gaurava Agarwal about the formation of that program, which has been a great success here at Northwestern. So what motivated you to do a Scholars of Wellness project initially? And was there anything about peer support and the field of OB/GYN that was very important for you?
Dr. Chaudhari: Yes, absolutely. So, I'm a big fan of our Scholars of Wellness program. I've gotten to continue to be a part of our advisory board, accepting applications into that program since I graduated from the inaugural class of that program back in 2018. What really struck me about the Scholars of Wellness program is really how innovative that program was. Rather than telling all of us, as physicians, what administrators thought would make us well or what would improve our physician burnout, Scholars of Wellness really took it to a grassroots level and sent out emails to the entire medical staff, asking us to submit proposals for our individual departments. And when I saw that, when I saw the initial email and the proposal, I was sort of overturned that somebody would actually want my opinion and potentially would help me get a project off the ground and running for my department.
Peer support, I think, it really impacts all physicians, but in the department of OB/GYN, especially in as busy of a department of OB/GYN as we have here at Northwestern at the Prentice Women's Hospital, what we know is that, OB/GYNs, we take care of people at the best of their times, when they're delivering their babies, when they meet their babies for the first time. We cry with them, when they get to hold their child that they've been waiting for so long. But we also unfortunately are there at people's absolute worst times, whether that's a horrible surgical complication, an infant death, a miscarriage, a maternal death. And so our roles as physicians are very dichotomous. And I think for many physicians, they're often there at the worst of patients' times, when they're caring for patients when they're very, very sick.
But we are on both ends of that high, and I feel like that takes a real toll on the mental health of OB/GYN providers, that we are usually so upbeat and so happy, but then we go in and we have to tell someone really horrible news, maybe it's a cancer diagnosis, maybe it's miscarriage. And then we walk into the next room and we need to be up and ready for that person to meet their child for the first time, an event that really is life-changing for them. And I think that dichotomy really lends itself to needing peer support, finding a way to better cope with those ups and downs of our work. And I think we, as physicians, who are actually in that work every day are probably best set up to help us cope and figure out how to move forward from the bad days.
Dr. Jin: Right. Yeah. I honestly cannot even imagine going through something like that and having to shift gears so quickly from one patient then immediately to the next. And can you define what peer support means in this context? What would be an example of providing, as a peer, your colleague with support in a time of need?
Dr. Chaudhari: I think peer support is a word that we use frequently, and it's used in so many different organizations. I think probably the most famous sort of peer support program is Alcoholics Anonymous, right? We've all heard of it—the 12 steps—and they've been the most successful and have some of the best results that anyone's ever published upon.
When we think about peer support when it comes to physicians and adverse events, we're really focused on what I call emotional first aid, which is the idea of bringing trauma-informed care and first aid to our physicians at the ground level when they are experiencing an event or a difficult or distressful patient situation. That they have a colleague that they can talk to in a confidential manner in order to recognize that the feelings they're having are normal and appropriate and that it's okay to not always be the person that has to be in charge or has to be perfect in every event. And I think that's really hard for us as physicians, Jill. I think we often feel like we have to be the one who supports all the family members of that patient or the entire team as an attending physician. And really sometimes, we need a moment for ourselves to be able to cope with the situation as it happens.
Dr. Jin: Exactly. It's so true. It seems so dated, but I feel like we're still so trained to just be stoic and to not ask for help, and there's still a little bit of stigma against any mental health needs and concerns. And to be honest, I'm just surprised that it has taken this long for institutions as large as Northwestern to even develop this program, and that it's not more widespread and more universal around the country and the world.
And tell me about what steps you took to establish this peer support program from the original conception to first the up-and-running department-wide program within OB/GYN?
Dr. Chaudhari: Really, this started as sort of a pie-in-the-sky idea. I looked at colleagues who I felt like were struggling after these events, and as individuals, many of us would go and try to support them after these events. But really when I started, I didn't really have an idea about how to mobilize this and how to get buy-in and how to get referrals into the program. And so, Scholars of Wellness was really instrumental in introducing me to quality improvement methodology.
And what we learned and really utilized for our Scholars of Wellness program was the DMAIC method. So really looking at what the voice of my customer was, what problems did my physicians think we needed to address, and was peer support even part of that problem? And then we went on and really tried to figure out what we wanted to measure and how we were going to implement it and who the parties were that we had to get involved.
It was really lucky for me that I had a very supportive chairman and department administrator who really had heard the same things I was hearing, that our colleagues were craving the support and the community around them to help them through these adverse events. And so I really had good people as my right-hand people to help me really get engagement both at a leadership level as well as at a department level.
Dr. Jin: And just to clarify, so DMAIC is define, measure, analyze, improve and control. And that is a quality improvement process if I'm not mistaken, correct?
Dr. Chaudhari: That's correct. That's correct.
Dr. Jin: Okay.
Dr. Chaudhari: And that was what was really taught to us by our quality improvement people here at Northwestern. And though I'd read about that methodology before, it was really amazing to have someone coach you and walk you through it on an individual basis as you tried to apply it to something that you were passionate about.
Dr. Jin: And any particular challenges or lessons learned from that process? It sounds like you did have great support from leadership, which is key and is not always the case, so that we’re already off to a great start with that. But any big challenges or any lessons that you can share with us?
Dr. Chaudhari: Yes. So within the department I actually felt sort of very validated. It was like a very uplifting experience, because so many of my colleagues were so excited that we were finally starting this program. We had a lot of volunteers who volunteered early on to sort of be peer supporters.
But one of my first real obstacles was figuring out who needed the support. How was I going to figure out who we should be calling on to support them? And it turned out that we needed to create a lot of partnerships as well as create a lot of reminding systems. We really partnered with our risk management here at Northwestern to have them begin a referral process to us. And even despite multiple calls, still to this day, I meet with them on a quarterly basis to remind them that we're here, because it's never been a part of culture to offer sort of collegial support to a colleague. We've always offered mental health support through employee assistance services or legal support if we were worried a case could turn sort of downhill. But the idea of offering emotional support from a colleague has just never been present in the institution. And so, really in addition to getting sort of buy-in from those groups, it was really starting to change culture and process to try to get those referrals to us so we could really help the people that we needed.
Dr. Jin: That's very telling that the challenge wasn't getting volunteer peer supporters, but rather the people who needed support.
Dr. Chaudhari: It was, I think, Jill. And I think just to add to that, I think one of the things is, again, as physicians we put up this persona that we're perfect and we can handle it. And I can quote one of my risk managers who said to me, "Whenever I ask them if they want employee assistance services, the response is always, 'No, no, no, I'm fine. I'm fine. I'm worried about the patient' or 'I'm worried about the family' or 'I'm worried this could turn into a legal matter, but I'm fine.'"
And the answer to that is we're really not fine, right? Like we just put up that persona and then they go home and they struggle and they can't sleep, and they yell at their families and behave in all the ways we know when we're trying to cope with a really difficult situation.
Dr. Jin: Yeah. I'm just imagining myself in that situation. Part of it would be, "Oh, I don't want to bother my peers who have five billion other things to do, and their time is limited." But the fact that you're saying you've got so many volunteers who are truly volunteering their time and trying to help and wanting to help, I mean that speaks volumes and it's reassuring. And if anything, hopefully, that can be a motivating factor for people to seek support as well. Their colleagues want to do it. They want to help.
Dr. Chaudhari: Yes, and Jill, now that we've been running this program, I will tell you, my supporters, you don't know the number of times even in a week where I get emails or texts from my supporters after I've assigned them a case. And they will text me and say, "I feel like I got more out of that support session than the person I supported. It was so amazing to connect with a colleague and to hear what they're going through and talk about shared experiences. I feel like I've made a new friend." Or, "I feel like I’ve made connections with someone that I maybe wouldn't have before." And it means a lot to the supporters as well.
Dr. Jin: Wow. Yeah. That must be so validating for you to hear as well that it's beneficial for both sides. That's great. So, tell me again, what is your outreach process now for within your department?
Dr. Chaudhari: We speak frequently about our peer support program. We actually started this program under Scholars of Wellness as an attending physician peer support program, but actually have expanded it to our residents and our trainees as well. I have served as the associate program director for a number of years and as part of that role I get a lot of referrals from residents, from nurses, from attending staff telling me when they feel a resident was involved in a difficult case as well. And so now our process comes from so many sources in addition to risk management. Like I mentioned, we have nurses that come and refer to us. We have attending physicians of trainees. We have colleagues that maybe will even just see someone crying in the hallway and didn't feel comfortable going to talk with them and saying, "I don't know what's going on, but I think so-and-so might really benefit from a reach out from the peer support program."
So in our department it's really turned into a cultural thing. Everyone knows about it. They expect they're going to get calls. They look forward to those calls as a place where they can confidentially talk about a problem with someone maybe they didn't feel like they wanted to bother or have them take time out of their day. But because we call and reach out they feel much more comfortable having those conversations, and I really think it's gone a long way to improve the collegiality of the culture of our department.
Dr. Jin: Yeah, absolutely. Are most of your referrals peer referrals as opposed to self-referrals still?
Dr. Chaudhari: We still get a number of self-referrals and it's actually interesting, within the department, because we are a very large department. We have over 220 doctors in our department, but we still are a pretty tight community. We have lots of meetings that we do all together and people do know each other and we try to learn the new people as our groups hire. But a number of our physicians still are looking for support on their own. And sometimes I'll actually get a self-referral that says, "Hey, I'd really love to talk to another doc who went through the six months after coming back from maternity leave. I'm really struggling with some of these cases." Or you know, "I'm really struggling with an event. Is there somebody else who's had a maternal death? Because I really think I need to talk with someone who's seen that before." And so I do occasionally get those peer referrals from people asking for either very specific people or very specific scenarios that people maybe have experienced.
Dr. Jin: Okay. So, it sounds like the OB/GYN peer support program has really been a huge success. Like you were saying, it's become part of the departmental culture and it's just widely accepted and known as an entity now. And subsequently, this has been scaled up to the rest of Northwestern, to the rest of the organization, which I believe is the effort that you led as well. Tell us about that process and any challenges or lessons learned from that.
Dr. Chaudhari: Absolutely. So yes, we have actually scaled up. After our departmental program was in place for approximately six months, I was approached by Dr. Agarwal to scale this first to Northwestern Memorial Hospital, our central region, for Northwestern. And as part of that, getting to lead those efforts, really looking to expand the number of peer supporters across departments and figuring out the best ways to try to integrate this into hospital culture, which as you can imagine, Jill, is a lot more challenging than doing it within my department where everybody knows me. And so we spent a long time trying to figure out what had been working in the department of OB/GYN and seeing if we needed to make any major changes at the hospital level.
And a few things that kind of came up as challenges is, as I mentioned, we utilized risk management as one of our resources to really get referrals to our OB/GYN peer support network. I did find that here at Northwestern, our OB/GYN department uses risk management much more frequently from a reporting standpoint than the rest of the institution. And so what we found was that risk management alone might not be our only place to look for a source of referrals.
I also went forward and really tried to engage leadership at many, many different levels. So not just speaking to chair meetings or department administrator meetings, but also trying to get to as many faculty meetings and division meetings as possible. This was, I like to call it, our peer support road show, trying to get around the hospital and try to explain the program as best we could to people who have very, very different experiences than my own. You know, as an OB/GYN, I could very much relate to what my colleagues go through, but I don't necessarily know what an adverse event looks like for a dermatologist, or for a pulmonologist or for a urologic surgeon.
And so as we did this sort of road show around our faculty division meetings, part of it was for me to get a better understanding of what the needs of those different departments were, as well as to sort of explain what our program was and how we could be available to help them. And on that road show I actually picked up a lot of volunteer peer supporters, people who would reach out to me afterwards and say, "Hey, I want to be trained as a peer supporter. I think this is something that I could really be good at." Or "I really think helping my fellow physician is something I find very honorable, and I think I'd get a lot of satisfaction out of it," which was amazing. Basically, every faculty meeting I went to, I picked up at least one volunteer peer supporter, which was so great. And so, that was a real challenge, though.
And I'll tell you, there was a lot of skepticism when we started. There was a lot of questions regarding, "So who's looking over your shoulder? Who's going to know that I came to the program for peer support? Who's going to know that I accepted the peer support that was offered to me? And what does that mean? Is it going to be reported to my chairman? Is it going to be reported to the dean?"
And part of the program when I went hospital-wide was to really iron out some of those things, because for me, the most important thing if I'm going to be giving collegial peer support is to ensure confidentiality for the people we're supporting as well as for our supporters. And so that was something that we had to work through with our legal department, our medical staff office, our quality department.
There's still discussions about how to continue to better integrate this program into the entire hospital culture, but at this point we report out to our medical staff office, and I don't give individual names, ever. I actually don't keep track of them. I can't survey them afterwards because I don't know who ends up utilizing our support. I only track it by department and month that those referrals are coming in. And so, in that way, I'm doing my best to ensure confidentiality for my colleagues who are looking for peer support.
Dr. Jin: You were saying you do have the numbers by department division? Do you have a sense of what percent of physicians are seeking out peer support on a hospital level at this time?
Dr. Chaudhari: Yeah. Yeah. That's a great question. It's actually very hard to track. What I will tell you is that over the last year since we started our hospital-wide peer support program, we've had over 120 reach-outs to physicians from supporters. And to put that into perspective, we actually looked at the numbers for the year prior to the COVID pandemic, of course, and we looked at 2019 and saw that only seven physicians across our entire hospital system had actually used employee assistance services, which was previously our only sort of mental health resource available.
And so when we look at this last year of over 120 reach-outs, that number is dramatic—dramatically different about the number of physicians we're reaching out to talk to. So, it's hard to get a denominator on that number. How many people aren't reaching out for peer support, right? But what we know is that already we're continuing to expand our services. We're looking to support people through peer review and legal cases. We're looking to support people through discriminatory patient encounters, or honestly, with the pandemic, compassion fatigue, the frustration that so many of our providers have when they see patients who get sick who aren't vaccinated, or who maybe aren't taking their medications as prescribed and getting more and more ill. And so as we've sort of expanded what our reach is in terms of support, I anticipate we'll continue to see growth, especially as it becomes more integrated into the culture.
Dr. Jin: I certainly hope so. I think, yeah, the increase from seven to 120 is fantastic, but as you said, probably it's still not enough. You know, I think with burnout rates being estimated from anywhere to 40-50%, you know, a physician is experiencing some sort of burnout, I do hope that it continues to expand. And I really am so impressed and awed by all this work that you have done.
Tell me a little bit more about the timeline in terms of how long did it take for the initial OB/GYN program to get up and running and then for the scale-up process to begin?
Dr. Chaudhari: It was like a labor of love, Jill. When I officially put up our departmental program, I was in a rush. I like to get things done. I'm efficient. I'm a project person. "Let's get this up and rolling." And what I found was I really needed to be much more deliberate in the way we did those rollouts. What I mean by that is I really wanted to ensure the product, the project that I was doing, was really beneficial for the people within my department. And so by surveying them, by getting individual feedback, by doing just qualitative assessments in verbal discussions with people, I was really able to get an idea of what people were looking for.
And then, when we elicited volunteer supporters, I found that, yes, these were all amazing and empathic people I would've chosen myself, but that actually we all needed much more formal training in emotional first aid. We know how to be empathic. We know how to care well for patients. But emotional first aid requires a slightly different skill set than typical doctoring, because you're caring for your colleagues.
And if any of us have taken care of patients who are colleagues, we know that sometimes we care for them a little bit differently. We sometimes let them lead their own care. And really, as peer supporters, I wanted my peer supporters to feel comfortable going into those interactions with a knowledge base that was worthwhile. So we really spent some time training those supporters as well.
So my initial timeline was about six months to get all that done before we sort of hit the ground running. We've definitely made changes in the program as we've continued, mostly based on feedback. And a lot of sort of our expansion of the program within the hospital, to really support not just adverse events but also compassion fatigue, peer review, discriminatory patient events, has really come from feedback from the peer supporters as well as from colleagues around the hospital, really saying, "Adverse events are great, but actually, you know what I really need support over right now? It was about being quarantined away from my family for four weeks during COVID." Right? And so some of those are sort of how we've changed over time.
Similarly, when we moved into the hospital system, we spent another six months. And really the goal of that six months was trying to get buy-in from a lot of leaders of different departments around the hospital, really trying to hear what they needed and what their biggest concerns were. And I'll tell you, confidentiality was probably the number one that came up time and time again, and then really ensuring that our volunteer peer supporters were again the same empathic people I had chosen for my department, but at a much larger scale where I maybe didn't know all of them and trying to figure out who the right people were to direct me to those people.
And then again, we went through a training process for all those peer supporters in order to ensure that they felt comfortable with emotional first aid. We also do some voluntary simulated sessions that we can sit down and do, and basically do a mock peer support session with those docs to really help them feel more comfortable in those situations. And even then, myself and Dr. Agarwal act as a resource in case they do get over their head, they get asked questions they don't know or they're very worried about a physician who might need more help than a colleague can provide.
And so that again was about a six-month rollout before we went live. We were very lucky that that six months ended basically in February of 2020, the same time the pandemic was hitting our hospital. And so we were very quickly able to pivot and allow support around COVID-related things as well.
And then about six months later we said, "Okay, it's time. We're going to take this organization-wide." And so that took a little longer, about 9 to 12 months to really get leadership at a very, very high level to buy into this, to find the right people to help us lead these efforts at a local level. I felt very strongly that we needed local leadership at each of our institutions to really ensure that the culture of those institutions is being represented in the peer support program. And so that's been really a year labor of love getting that started. And we went live September 1, so we're really, really excited and proud of what we've been able to accomplish.
Dr. Jin: Wow. I know six months sounds like a long time to you, but truly, I mean, in the grand scheme of any organizational change, that's astounding. I mean, I feel like it takes six months for us to get a new printer in the office. I think to create a peer support program in six months, and then 12 months later, scale it up, that's—I mean, that’s inspirational that physicians who, like yourself, just had an idea and wanted to help, can truly become change leaders, whether it's through a formal program such as the Scholars of Wellness or just through working with the organizational leaders who are supportive and able to offer help. So that, I think, is what we are trying to do at AMA STEPS Forward® is really inspiring people, physicians who are innovative thinkers and change leaders, inspiring them to believe in themselves to make this change and to create system-level change.
Do you have any final kernels of wisdom for physicians such as yourself?
Dr. Chaudhari: Well, I would say, don't give up. Find not just mentorship, but sponsorship people who really are in a position to help you get where you want to be. I was very lucky to have that in my own department and then be able to create sort of change at a much larger level. I would say that this process can be tedious. There are a lot of naysayers, as you can imagine, Jill. There are a lot of people who still are worried about the confidentiality. They're still worried that the organization at large is not thinking about their well-being. And I often tell people, you know, if the organization isn't, I am, the people who are supporting you are. And really, to work to create culture, I think it needs to be started at an individual basis and we can work our way up to creating it on a more organizational level.
Dr. Jin: Well, thank you so much, Angela, for your time and your expertise and words of wisdom and inspiration to us all. Truly, I think that this success story, which is truly exactly that, a story of success, from a pie-in-the-sky idea all the way to an organizational-wide program that is benefiting hundreds of physicians. So, I can't thank you enough for that and for taking the time to share that story with us today.
Dr. Chaudhari: Thank you so much for having me today, Jill.
Speaker: Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA's STEPS Forward® program is open access and free to all at stepsforward.org. STEPS Forward® can help put the joy back into medicine by offering real world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA's STEPS Forward® podcast series, stepsforward.org.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
