The number of medical malpractice claims has not changed significantly in the past 10 years(1); 95% of full-time emergency physicians will face medical malpractice litigation.(2) Malpractice claims raise concerns about patient safety and provider emotional and psychological well-being. Research has demonstrated that experiencing a malpractice lawsuit is traumatizing for physician defendants.(3) The impact of this stressor has been characterized as a type of post-traumatic stress disorder (PTSD) called medical malpractice stress syndrome (MMSS).(4)
Most physicians enter medicine committed to helping people and therefore consider a lawsuit alleging error, negligence, or incompetence injurious to their identity.(5) Malpractice cases often last many years, during which time the physician may suffer from feelings of isolation, anger, guilt, anxiety, depression, negative self-image, helplessness, and hopelessness. They may even experience suicidality.(6)
Experiencing a malpractice lawsuit is a practice-changing event for many physicians, causing some to leave medicine altogether. Physicians are increasingly likely to leave medicine as the number of malpractice claims rises, with a 9% higher risk after one claim and a 45% increase after five or more.(7)
Albert Wu described the distressed physician after a medical error or bad outcome as the “second victim” (with the patient being the first victim).(8) The term itself has come into opposition in recent years,(9,10) so we will refer to “secondary trauma” instead.
Approximately half of healthcare providers will experience secondary trauma in their careers and often suffer in isolation. For many years, experts have recommended that healthcare leaders provide formal support.(11) Formal peer support programs have become a best practice to help healthcare providers deal with this stress and even develop wisdom from post-traumatic growth.(12)
Examples of peer support programs include the Brigham and Women’s Hospital’s Center for Professionalism and Peer Support,(13) the RISE (Resilience in Stressful Events) program at Johns Hopkins,(14) Stanford University’s Physician Peer Support Program,(15) and Kaiser Permanente Northern California (KPNC)’s Peer Outreach Support Team (POST) program.(16)
Concurrent with the rise of the physician wellness movement is the implementation of just culture initiatives. The traditional “blame and shame” approach can be traumatizing and often does not lead to systemic improvement. Just culture shifts culpability from the individual to the system and emphasizes learning to improve care.(17)
The principles of just culture are predicated on the theory that learning can only occur with open dialogue and clinicians’ perceptions of trust and fairness in a setting with a strong culture of wellness and safety. Peer support has the potential to powerfully augment this culture change.
In a recent NEJM Perspective piece, Jo Shapiro and Timothy McDonald describe the “culture of silence” in the medical profession, which causes isolation and suggestions that other providers are better at handling workplace stressors.(18) Shapiro and colleagues also describe how physicians prefer to receive support from their peers rather than from mental health professionals.(19) The emotional stressors that physicians face are occupational hazards and should be treated as such; the peer support model reduces stigma and the false perception that others are more resilient.
In the Department of Emergency Medicine at a large academic tertiary care center in New York City, we began by holding quarterly faculty peer support groups called Doc Box, during which faculty share their stories and coping strategies and create community.
In 2017, Doc Box’s popularity led us to implement a self-referral peer support program. With enthusiasm at the outset, we educated our faculty about secondary trauma and malpractice stress and then provided readily available peer support contacts for physicians undergoing quality review investigations and lawsuits. Yet over the next few years, we received very few calls.
A review of the medical literature and our own experience demonstrates that physicians are unlikely to self-refer to peer support programs.(13,19) To fill this gap, we developed a case-based faculty peer support program. Recognizing that physicians are unlikely to seek support independently, the program was intentionally designed as an opt-out model, ensuring that all faculty involved in litigation or a quality review case are offered support.
Specifically, our SMART aim was to achieve greater than 80% agreement (strongly agree or agree) with the statement “the peer support program is a valuable resource” on a post-implementation survey by July 2022.
THE METHODOLOGY
Project Setting
This pilot project was implemented in 2021 in the department of emergency medicine within a large academic medical center in New York City. NewYork-Presbyterian/Weill Cornell Medical Center and NYP/Lower Manhattan Hospital campuses provide emergency care to more than 140,000 patients annually. NYP/Weill Cornell is a level 1 trauma center, and both campuses are notable for high acuity and diversity in an increasingly complex healthcare environment. The department of EM also provides clinical, academic, and research training in adult and pediatric emergency medicine.
Study Design
We used quality improvement (QI) methodology to define our SMART aim and family of measures. We used pre- and post-study design to assess the effects of our interventions.
Outcome Measures: Satisfaction with the peer support program as indicated by those faculty who received support and those who provided peer support.
Process Measures: The number of peer support pairings assigned and the number of subject physicians who opted out of peer support.
Balancing Measures: Vicarious traumatization of the peer supporters and lawsuit discovery of the conversations, i.e., the potential for the peer supporter to be subpoenaed or the person being sued to have to reveal details of their peer support conversation in a deposition.
We addressed vicarious traumatization via an optional meeting for peer supporters every other month. This was an interdisciplinary discussion with our fellow peer supporters in the department of anesthesia and a chaplain to assist in moderating the discussion.
Peer support training mitigated lawsuit discovery. The goal was to focus discussions on the emotional impact of the cases and minimize discussing the details of the cases themselves. In keeping with previous programs,(3,11,13,16) hospital legal experts advised that the legal risk of peer support is extremely low.
Study of Intervention
Peer Support Program
Starting in September 2021, we established a case-based, opt-out peer support program. We created a three-hour peer supporter training program based on previously published work(13) and recruited 18 faculty members to serve as trained peer supporters. The only prerequisite was that they, themselves, had experienced a quality case review or lawsuit.
Peer support conversations are grounded in reflective listening, focusing on full attention, emotional validation, and thoughtful responses. They also include reframing, coping strategies, and shared experiences when appropriate, ensuring consistent, compassionate support for litigation and quality review cases.
Over the course of one year, our director of quality improvement provided our peer support team with the names of physicians involved in open quality assurance cases and lawsuits. The peer support team leader then assigned a trained peer supporter to connect with the physician.
In addition to developing the peer support program, the group also worked to change the department’s culture by presenting data about it during faculty meetings, leading discussions about secondary trauma and malpractice stress, and holding group peer support meetings called Doc Box.
For one year, our director of quality improvement referred physicians to our peer support team, and we paired them with trained peer supporters who had been through the process themselves. The peer supporter connected with the subject physician at mutually convenient times. The program naturally expanded to include leadership referrals and self-referrals, some of which were not specific to a medical case.
Data Collection
We collected data via the Needs Assessment Survey to inform the format and content of our program and the Peer Support Survey for Case-Based Peer Support Program to understand the program’s impact on faculty who received support and those who provided support. According to institutional review board (IRB) policies at our institution, this work met the criteria for quality improvement activities and was exempt from IRB review.
Needs Assessment Survey. We created this survey for our entire faculty group based on the described symptoms of secondary trauma and malpractice stress.(4,5,8,11) This survey has 29 questions: Questions 1 and 2 capture demographic information (area of practice: adult or pediatric) and years in practice. Questions 3–12 assess the experience, subjective impact on well-being, type of support used, and desire for a formal opt-out peer support program. Questions 13–28 assess the same areas as above but in relation to lawsuits. The final question is the single-item Mini-Z question on burnout.(20) The Mini-Z survey was named for Linzer, et al.’s Zero Burnout Program.(21) Most are “yes/no” questions with some responses on a Likert scale, 1–4, with 1 being strongly agree and 4 being strongly disagree. (See Supplemental Survey 1.)
Peer Support Satisfaction Survey for Case-Based Peer Support Program. This survey assessed the experiences of faculty who were offered peer support and faculty who provided peer support. Therefore, this survey has two sections (See Supplemental Survey 2). For those offered support, a single survey asked them to recall how they felt before and after peer support.
Section I: Faculty Receiving Peer Support was used and adapted with permission from Jo Shapiro. It offered opt-in/opt-out options to capture the reason(s) those who opted out of the program did so.
First, we aimed to assess the impact of the program on the emotional well-being of participants before and after participating in the program and specifically focus on the stress responses regarding the adverse event (“I felt ashamed,” “I questioned my own clinical competencies,” “I kept thinking about the event more than I wanted to,” “I felt my colleagues were judging me negatively,” and “I was concerned about professional consequences (e.g., medicolegal).”
Second, we asked participants to reflect on their peer support experience and its impact on participants’ coping mechanisms, how valuable the support program is as a resource, who should be a peer supporter, and whether they would recommend it to other faculty involved in adverse events. The responses were captured using a Likert scale 1–4 (1 being strongly agree and 4 being strongly disagree).
Section II. Faculty Providing Peer Support was partly designed based on the RISE program’s published survey.(14) We asked peer supporters to rate their experience using a Likert scale 1–4 (1 being strongly agree and 4 being strongly disagree) with statements designed to capture their comfort being a listener, responding to questions, need for additional training, whether role play should be included in the training, and overall satisfaction being a peer supporter.
Lastly, we used one question that asked all participants to self-assess burnout and a free-text section to add comments and/or suggestions on how to improve the program. Of note, faculty were invited to participate via a group email containing an anonymous survey link to a web-based survey.
Data Analysis
We analyzed data collected from physicians who completed both surveys. We calculated descriptive statistics on physician characteristics using proportions for categorical variables and medians for continuous variables. We compared participants’ stress responses regarding the adverse event before and after receiving the peer support using the exact McNemar’s test to control for the paired nature of the data. We used R statistical software, version 4.3.2, R Foundation for Statistical Computing, Vienna, Austria.
THE RESULTS
Needs Assessment Survey
We will highlight portions of the survey results in the text and in tables. For the full survey results, please see Supplemental Table 1, Sections A, B, C, and D.
Demographic Characteristics (Supplemental Table 1, Section A)
Out of 100 faculty members, 66 responded to this survey (RR = 66 %); 46 (70%) were adult EM faculty members, and 20 (30%) were pediatric EM faculty members. There was no difference in the distribution of years spent in practice between pediatric and adult EM physicians (P = 0.062).Experience with Quality Assurance (QA) Case Review (Supplemental Table 1, Section B)
Out of 63 faculty respondents, 59% (n = 37) reported having experienced a quality case review. A majority experienced emotional stress because of this experience (37 of 39 respondents, 95%), of which 33 (89%) thought it would have been helpful to be assigned another faculty member who had been through the process to serve as a peer supporter.Experience with Medical Malpractice Litigation (Supplemental Table 1, Section C)
Similarly, out of 62 EM faculty respondents, 56% (n = 35) reported having been named in a lawsuit. Thirty-six respondents provided answers to the number of lawsuits: 16 (44%) had experienced one lawsuit, and 12 (33%) had experienced two lawsuits. Only one had five or more lawsuits (3%). Of 36 respondents, 24 (67%) reported having a case that lasted longer than three years. Case outcomes were similar to nationally reported data. (Supplemental Table I, Section C)
Like QA case review, out of 35 faculty, almost all (91%; n=32) experienced emotional distress related to the lawsuit. Thirty-one of 36 (89%) respondents would have liked to have had a colleague as a supporter, 17 (47%) had experiences that negatively affected their practice, while 23 (72%) reported that they learned something from the experience of being involved in a lawsuit that would be valuable to share with other clinicians. (Supplemental Table I, Section C)
We compared stress responses to QA vs. medical malpractice litigation and found that they were equally stressful (Figure 1).
More importantly, when asked who they reached out to for support during these stressful times, the most common answer was “colleague,” which is consistent with previous articles that have found that physicians prefer speaking to their peers.(11,19) Burnout responses in our Needs Assessment Survey were lower than nationally reported data at that time.(22) (Supplemental Table 1, Section D)
Figure 1. Stress responses for the quality assurance case review vs. medical malpractice litigation were similar.
Process Measures
During the study period, 11 faculty physicians were involved in 15 cases, either through quality assurance case review, difficult clinical cases, or medical malpractice cases. Four out of 11 faculty had two cases each, contributing to 15 cases (some of which were self-referrals after difficult cases). Peer support was accepted for 11 out of 15 cases, so the overall acceptance rate for the peer support program was 73%.
Outcome Measures
Peer Support Satisfaction Survey for Case-Based Peer Support Program (Supplemental Table 2, Sections I and II)
Section I: Faculty Receiving Peer Support. Overall satisfaction with the peer support program was high: 100% (n = 9) of faculty respondents who received support reported that they strongly agree/agree with the statement that the support program was a valuable resource, achieving our SMART aim. (Two of eleven did not respond to the question.) The impact of the support program on participants’ well-being is shown in Figure 2. We saw subjective improvement in all stress responses.
Figure 2. Self-reported well-being assessment before and after participation in the peer support program showing an improvement for all questions with “I was concerned about professional consequences, e.g., medicolegal” response reaching statistical significance (P < 0.03).
Section II. Faculty Providing Peer Support. Nine faculty peer supporters supported the 15 cases paired during the study period (see above), and seven responded to this survey (RR = 88%); the ninth peer supporter was the primary author and thus not included in the survey.
All peer supporters reported that they strongly agree/agree with feeling comfortable providing support and responding to questions and that the interaction was beneficial to faculty receiving support. Out of seven faculty members, five (71%) faculty responded that they would like additional training as a peer supporter (Supplemental Table 2, Section II). Some free text comments included:
“It placed everything in perspective and knowing that a colleague whom I trust and respect knew what was going on made me feel quite supported!”
“My peer supporter provided validation and helped me share my frustrations instead of bottling in.”
“Receiving peer support was an overwhelmingly positive experience.”
“Peer support is good for everyone involved.”
Balancing Measures
We did not have any cases of vicarious traumatization of the peer supporters or lawsuit discovery of the conversations.
DISCUSSION
In this pilot study of a newly developed case-based peer support program, we found that it was both desired and well-received. Those who accepted support felt a subjective benefit, and likewise, the peer supporters found the interactions to be beneficial.
Our needs assessment survey confirmed that our physicians faced a significant number of malpractice and quality review cases that were on par with national data. For example, in one 2011 NEJM study, the authors projected that roughly 55% of physicians in internal medicine and its subspecialties were projected to face a malpractice claim by the age of 45 and 89% by the age of 65.(23)
Our survey also found that physicians consider these cases extremely stressful, highlighting the need to develop peer support programs. Anecdotally, the faculty found the presentation of the needs assessment results therapeutic and revealing. Culturally, physicians do not talk openly about their lawsuits or case reviews. Many were surprised and reassured by the significant numbers in our midst.
This highlights the fact that physicians are less likely to seek help on their own. Therefore, we used a recommended opt-out approach to normalize the assignment of a peer supporter for every case of malpractice or quality review.(13) Peer support should be the norm in a career that requires interaction with tragedy, suffering, and even potential catastrophic errors.
Our program paired physicians with the same specialty within the same department to provide an authentic peer who has “walked in their shoes.”(10,19) We are optimistic that this peer support program will draw faculty closer and lead to a culture of openness rather than the traditional culture of isolation.(18) Further study should compare intradepartmental vs. pairing outside the department, as there may also be the benefit of minimizing shame or judgment with an external peer supporter.
Our pre- and post-intervention comparison of stress responses showed a trend toward stress reduction, and we found significant improvement in concerns related to professional consequences, e.g., medicolegal. Overall, and in keeping with previously published data on peer support,(13,14,16) the program was thought to be beneficial by both the peer supporters and those receiving support.
LIMITATIONS
While our one-year survey results show the program’s subjective benefits, the results and ability to do any statistical analysis are limited by the small number of participants in this pilot project. This study involves a single academic center and a single department of emergency medicine in New York City, and results may not be generalizable to other settings.
The survey for those offered support is potentially limited by recall bias. There was also no control group of physicians who were not offered peer support, so it is possible that the passage of time could have accounted for some improvement. We also limited our intervention to faculty physicians in the Department of Emergency Medicine. It is likely that nurses, residents, and other healthcare providers could similarly benefit.
The benefits of peer support can be specific to the individual receiving peer support. It is challenging to measure objective markers of well-being, given the presence of many confounding variables. These results may or may not be generalizable to a large faculty group. What is also unanswered is how best to help those who decline support. These individuals may need the most support and resources; however, these physicians may already perceive a just culture and feel adequately supported or even reassured by the knowledge that a peer support program exists.
In the survey of faculty peer supporters, 71% of respondents reported that they desired more peer support training, specifically role-play training. Because of the time constraints of working with busy emergency physicians, we designed a short (three-hour) training program, including role play at the end. That said, the peer support interaction is mostly about listening and offering reassurance. This contrasts with how we often interview patients, where we ask targeted questions looking for data and problem-solving. Listening without fixing may be a change for physicians, who might benefit from additional training.
Another potential limitation of peer support programs is the issue of legal discoverability. While it is widely known that physicians should not be discussing the details of a legal case, it is generally considered safe to discuss their emotions with a peer supporter. In an ideal world, peer support programs would be legally protected from discoverability because discussing the details may allow physicians to relieve themselves of self-judgment and guilt. Unfortunately, this is not currently the case in New York, and significant physician advocacy is required to change this.(24)
In addition, peer support programs are potentially limited by the time required for development and implementation, as well as the time required by the peer supporters and those being supported. We are hopeful that institutions will follow the trend of acknowledging the program’s benefits by reimbursing physicians’ time, as is the case in Kaiser Permanente Northern California (KPNC)’s Peer Outreach Support Team (POST) program.(16)
While this program was a pilot project, future studies of peer support programs should ideally be longer and larger to allow for more statistical analysis of benefits.
CONCLUSION
Malpractice litigation, bad outcomes, and medical errors all create enormous psychological stress for physicians. In our faculty group, we found a need and desire for a case-based physician peer support program. Our survey found that a majority of physicians in a single urban academic emergency medicine department had experienced quality case review and litigation, and both were quite stressful.
After one year of peer support, both the peer supporters and those offered support found the program beneficial. The departmental and case-based nature of this peer support program makes it easy to replicate. We are optimistic that cultural transformation is underway, and we hope to move away from suffering in isolation and toward helping each other achieve emotionally healthy recovery from adverse events.
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