“Everybody in this room can understand”: A qualitative exploration of peer support during residency training

Abstract

Objectives

Though peer support groups are often utilized during residency training, the dynamics, content, and impact of social support offered through peer support are poorly understood. We explored trainee perceptions of the benefits, drawbacks, and optimal membership and facilitation of peer support groups.

Methods

After engaging in a peer support program at an emergency medicine residency program, 15 residents and 4 group facilitators participated in four focus groups in 2018. Interview questions explored the dynamics of group interactions, types of support offered, and psychological impacts of participation. The authors conducted a reflexive thematic analysis of data, performing iterative coding and organization of interview transcripts.

Results

Discussions with experienced senior residents and alumni normalized residents’ workplace struggles and provided them with insights into the trajectory of their residency experiences. Vulnerable group dialogue was enhanced by the use of “insider” participants; however, residents acknowledged the potential contributions of mental health professionals. Though groups occasionally utilized maladaptive coping strategies and lacked actual solutions, they also enhanced residents’ sense of belonging, willingness to share personal struggles, and ability to “reset” in the clinical environment.

Conclusions

Participants offered insights into the benefits and drawbacks of peer support as well as optimal peer group composition and facilitation. Support groups may be more effective if they engage a complementary model of alumni and pre‐briefed psychologist facilitators, avoid fatalism, and aim to foster intimate connections among residents. These findings can inform the development of future initiatives aiming to create a safe space for trainees to discuss workplace stressors.

INTRODUCTION

Burnout in medical residents has been linked to higher rates of loneliness, depression, suicide, and medical errors. ¹ , ² Recognizing that social support from colleagues is associated with increased resilience, decreased isolation, and lower burnout scores, ¹ , ³ , ⁴ , ⁵ , ⁶ peer support groups have become incorporated into physician wellness initiatives. ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹  Though some studies have explored the impact of peer support in practicing physicians and medical students, ¹² , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸  studies of medical residents are limited. ¹⁹ , ²⁰ , ²¹ , ²² , ²³ , ²⁴ , ²⁵ Additionally, existing studies have primarily utilized survey‐based tools to determine the efficacy of peer support without exploring a rich understanding of how the dynamics, membership, and facilitation of the peer groups contribute to effective social support. Given the ability of social support to encourage psychological resilience ²⁶ , ²⁷ and the potential drawbacks of poorly constructed peer support, ²⁸ , ²⁹ it is important to better understand trainee perceptions of the benefits, potential harms, and optimal characteristics of peer support.

METHODS

We performed a reflexive thematic analysis of our peer support program. ³⁰

Context

The peer support program was created to supplement existing residency wellness initiatives that include opt‐out counseling, a didactic wellness curriculum, and regular class check‐ins with program leadership. Sixty‐eight residents from a single emergency medicine residency program participated in the program. Residents were divided into groups of eight or nine individuals, each with residents from all 4 years of training. Group meetings were scheduled during protected educational conference time to minimize any time burden. ³¹ , ³² , ³³ Sessions were led by 15 alumni of the residency program, all of whom completed a 3‐h counseling training and were provided with mental health resources for distribution.

Participants

After the first year of the program, all resident participants and alumni facilitators were invited to participate in a focus group. Between May and June 2018, we recruited a convenience sample of 15 residents (3 PGY4, 4 PGY3, 4 PGY2, and 4 PGY1) to participate in three focus groups. To triangulate our data, we conducted an additional focus group with four alumni facilitators in August 2018.

Data collection

Each focus group consisted of four to six participants and was co‐facilitated by a nonphysician (AV) trained in focus group moderation and a faculty member at the emergency medicine training program (AJ). The semi‐structured interview guide (Appendix S1) included open‐ended questions exploring participants’ experiences. Interviews were recorded, transcribed, and de‐identified.

Analysis

Three authors (AJ, RT, JR) initially analyzed the first two transcripts, performing open coding to generate and refine code definitions. AJ, RT, and JR then combined codes into a single coding structure and independently analyzed all four transcripts. Subsequently, four authors (AJ, JR, RT, and JS) sorted codes into potential themes. AJ and JR then reviewed and refined themes before finally defining and naming the themes. ³⁰

This study was deemed exempt by the local Review Board.

RESULTS

Participants described the group dynamic created by the presence of senior residents and alumni facilitators, referenced the importance of distinguishing insiders from outsiders when considering group membership and facilitation, and commented on the perceived impacts of peer support on their psychological well‐being and sense of belonging. Representative quotations are included in Table 1.

TABLE 1.

Themes with exemplary quotations describing residents’ perceptions of the benefits, harms, and optimal characteristics of peer support

Theme	Subtheme	Description	Exemplary quotation
A more experienced other		Group dynamics created by the presence of senior residents and alumni facilitators
	Normalizing struggles	Finding comfort in knowing that senior residents encountered similar struggles during their training years	“It's not just peers, there are people who are even a year or two above you who I feel like are close to graduating and maybe have been doing this a little longer. I think that that sort of spectrum is helpful. Just crucial to know that you're not alone in any respect.” [FG2]
	Encouraging vulnerability	Senior individuals demonstrating their own vulnerability encouraged junior residents to share their experiences	“When a senior person kind of starts by opening up and sharing what they've been through…it kind of gives you more confidence like ‘alright it's okay to admit that I feel like I had this weakness.’” [FG3]
	Anticipated trajectory	Insight into the expected trajectory of the residency training years and life post‐residency	“My small group leader was an alumnus….I felt like she gave a lot of insight into what life is like once you finish this, and how things can be, and what she felt and what she had to do after residency to decompress something after 4 years of such high stress.” [FG3]
	Outing oneself	Fear that admitting vulnerability in front of senior residents might be mistaken for clinical weakness or ineptitude	“I think there's a fear that if you come forward and you talk about it, people will judge you and be like,’ she's not strong enough to be in this program or she's not bad ass as enough.’” [FG1]
	Fostering anxiety	The pessimistic nature of anticipatory guidance from senior group members might provoke anxiety in junior residents	“The [PGY] 4’s would start talking about how terrible third year was and… the 3’s and the 4’s were like, ‘Oh God I’m so glad second year's over.’ And the 1’s‐I don't think that's helpful for them. I think that just fosters some anxiety that they already have.” [FG4]
Insiders versus outsiders		The importance of distinguishing insiders from outsiders when considering group membership and facilitation
	Insiders can empathize	“Insider” individuals experiencing similar work stressors can empathize	“Everybody in this room can understand if I'm like, ‘Yo I was in West 7.’ Like, automatically you're in the place and you know exactly what – that's invaluable. Even my parents are doctors. They worked at county hospitals all their lives. They know crazy but it's not the same location of crazy. There's just something great about having somebody who's there.” [FG1]
	Ineffective support from outsiders	Challenges of articulating struggles to outsiders	“I find it hard to talk to people outside of the hospital about this stuff because they don't understand a lot of it and a lot of people's reactions I find really annoying. If I try to tell my parents, they're like, ‘But you're amazing and you're saving lives.’” [FG2]
	Faculty members as problematic insiders	Concern that burnout issues discussed with faculty facilitators might influence clinical evaluations	“I might have made some comment about feeling overwhelmed at one point in second year and attendings put things in my evaluation that said, “Seems like she's burnt out. Seems like she is struggling.” And that's not what you want in your evaluation if you're going to somebody to talk to them.” [FG4]
	Psychologists as outsiders	Concern that psychologists cannot relate to or understand workplace stressors	“[O]ne of the challenges that I had [with a therapist] was that we spent so much time answering questions about what it was like to be a doctor, what it was like to be a resident. They had no connection to what I was doing and I spent a lot of the time sort of explaining my job and myself in a way that I didn't want to be using that time for.” [FG4]
	Psychologists offer tools/solutions	Ability of psychologist‐ facilitators to provide tools to manage or detect burnout	“As much as an ex‐resident can tell us about their experience and what they went through, which is super valuable, it would be really helpful to have an unbiased outside view of this to not only identify patterns or the issues we are dealing with but also offer solutions that I think can be applicable in a more general sense.” [FG2]
Psychological outcomes		Perceived impact of peer support on residents’ psychological well‐being
	Increased self‐compassion	Increased self‐compassion as a result of participation in group discussions	Knowing that this is so common, feeling like what I’m going through is something that everyone has gone through or is going through. I think it allowed me to give myself a little bit of a break. For me, if I’m going through these struggles and my seniors or my peers endorse that as well, I don't feel like a failure, I don't feel like alone or hopeless, even if it's hard, I feel like I have support in this.” [FG2]
	Transient insight and resetting of values.	Reminder of former idealistic selves	“It's like a reset button. I came into my next shift a little bit more with my priorities straightened down. And to remind me that I like being compassionate.” [FG2]
	Spark hope	Sense of hope that current suffering can be overcome	“[Discussions with alumni] can spark a little bit of hope or something because you're like, “I really respect this person…. They were where I was and I can get there.” [FG2]
	Burnout as inescapable	Group discussions led to a perception of burnout as inevitable	“They were kind of a double‐edged sword because on the one hand it was reassuring to know that other people felt burnt out and felt weak and felt inadequate. On the other hand, it felt like it was an inevitability, because everybody had it.” [FG3]
	Venting without change	Perception that group conversations did not meaningfully impact burnout	“It's a good place to vent and just talk through the challenges we are facing, but if you want to address those problems and create change it's hard to have anything substantive come out of that, other than just feeling better because you talked about it. If you take a problem that really is systemic and structural, it should be fixed. There's nobody in that room that is necessarily in a position to make that change happen.” [FG1]
Connection and belonging		Perceived impact of peer support on residents’ sense of belonging
	Resident connection to community	Group discussions led to a deepened sense of belonging within the residency	“Having that space, it forces you to reconnect with everyone and bring out those feelings whether you're in a positive place or a negative place. I always felt like I left with a better perspective and feeling more a part of County [residency program].” [FG3]
	Expansion of networks	Group discussions resulted in an expansion of residents’ support networks	“But one of the nice things is you talk to people you're not as close with about some of the struggles they're dealing with and that does allow for being more compassionate about their struggles even if you're not as close with them in the residency. Also, I do feel like I felt a little more comfortable talking to other people at work and close friends of mine about those issues usually shortly after the sessions.” [FG1]

A more experienced other

Participants found comfort in knowing that the senior residents they idolized had encountered similar struggles during their training. Seeing senior individuals demonstrate their own vulnerability encouraged junior residents to share their experiences without fear of judgement. Alumni facilitators helped by clarifying the expected trajectory of the residency training years and characterizing life post‐residency through their personal narratives.

Though the presence of senior individuals encouraged group discussion, some junior residents feared that their vulnerability might be mistaken for clinical ineptitude. Additionally, some worried that the pessimistic nature of anticipatory guidance from senior residents might provoke anxiety in junior residents.

Insiders versus outsiders

Residents voiced a perception that only “insider” individuals experiencing similar work stressors could provide useful perspectives on these challenges. They noted a kinship built upon shared suffering, strengthened by an intimate understanding of the unique characteristics of their training environment. They also described the challenge of articulating their struggles to outsiders for fear of receiving judgment and noted that the adulation of their family members and societal expectations of physicians often inhibited genuine dialogue.

Interestingly, while acknowledging that program faculty possess an “insider” understanding of the residency experience, participants hypothesized that their inclusion in the groups would inhibit open dialogue. Residents expressed concern that demonstrations of vulnerability could influence evaluations of their clinical performance. With this rationale, they emphasized the importance of engaging program alumni as group facilitators. In their nonevaluative “insider” roles, program alumni were perceived as proximal enough to provide effective support while remaining distant enough to avoid influencing residents’ professional trajectories.

Participants expressed mixed sentiments about the potential inclusion of mental health professionals, voicing concern that psychologists, as outsiders, would not be able to fully grasp the nature of their workplace stressors. Despite this, residents acknowledged that alumni might be inadequately equipped to offer tools or coping strategies and suggested that the addition of psychologists as complementary facilitators could allow for recognition of residents in need of professional resources.

Psychological outcomes

By finding commonality in their workplace experiences, residents felt less isolated in their personal struggles and demonstrated greater self‐compassion. Group discussions allowed residents to perform self‐check‐ins and potentially identify peers in need of further support.

In addition to providing them with valuable self‐insight, residents noted that conversations with alumni reassured them that their current suffering would be temporary. They described a renewed sense of purpose and optimism and were reminded of their idealistic motivations for becoming physicians. Upon returning to the clinical environment, residents noted a heightened awareness of, and conscious desire to resist, their maladaptive attitudes and behaviors. They felt empowered to better navigate and take ownership of their personal struggles.

Though conversations with peers helped to normalize burnout, participants also noted that the sheer prevalence of suffering sometimes contributed to a perception of burnout as inescapable. Additionally, they acknowledged that group discussions were occasionally cloaked in negativity, with frequent use of gallows humor as a vehicle for commiseration. Ultimately, they viewed the groups as a structured mentoring system rather than a solution to burnout, perceiving burnout to be a deep‐seeded process ingrained in the structure of medical education.

Connection and belonging

After engaging in dialogue with their peers and seniors, residents noted that the peer group structure strengthened a sense of belonging within the residency network. Participants also reported an increased desire to check in on co‐residents that might be struggling, noting that the bonds they formed through the peer support program might inspire future dialogue.

DISCUSSION

In examining various domains of social support—tangible support, emotional support, and informational support ³⁴ , ³⁵ —residents highlighted the specific value of receiving informational support and anticipatory guidance from more experienced individuals. Peer support groups often prioritize emotional support without recognizing the importance of incorporating informative insights from those that have recovered from burnout. ²⁴ This finding highlights the value of including a diversity of learner levels and perspectives when structuring support groups.

While our participants found peer group discussions to be mostly beneficial, they noted that fatalistic portrayals of burnout by senior group members could be paradoxically anxiety provoking for junior residents. This suggests a potential drawback of social support—namely, the often unexplored gap between perceived support and received support. ³⁴ , ³⁶ Creators of peer support programs should train facilitators to guide group conversations away from excessive negativity, as fatalistic discussions of burnout might harm participants. ³⁷ Group leaders must allow time for shared suffering but also encourage participants to rediscover meaning in their work and engage in productive dialogue. ⁶ , ³⁸ , ³⁹

Our participants noted that facilitated group discussions offered a valuable space for sharing but were limited in providing solutions for their burnout. ⁴⁰ While simply debriefing after distressing situations can improve self‐efficacy and empowerment, ⁴¹ peer group participants may perceive discussions to be ineffective if program objectives are not made clear at the outset. Curriculum leaders should highlight the role of peer support in validating residents’ experiences, decreasing self‐imposed stigma, and promoting recovery from burnout ³⁹ while explicitly noting its limitations in preventing burnout.

When discussing group membership and facilitation, participants reported a preference for engaging with “insiders,” consistent with prior studies suggesting that physicians are reluctant to admit emotional vulnerability to nonphysicians. ¹¹ , ⁴²  The myth of physician infallibility ⁴³ , ⁴⁴ and a desire for outward perfection contribute to a fear that feelings will be minimized or dismissed by “outsiders.” ⁴⁰ , ⁴¹  While prior studies have highlighted the role of family and friends in promoting trainee well‐being during residency training, ⁴⁵ , ⁴⁶ our participants noted challenges in effectively communicating with loved ones. As a result of dissonance between their personal and professional identities, they instead preferentially sought the social congruence and empathy of their peers. ⁴⁷ Residency wellness interventions should attempt to enhance congruence between residents and their nonprofessional support networks, proactively providing family and friends with deeper insights into the residency training environment and common workplace stressors.

The involvement of program alumni as facilitators appears mutually beneficial, as alumni find meaning in reestablishing a connection to their former training program and trainees benefit from interacting with nonevaluative “insiders.” Alumni are an enthusiastic, highly regarded, untapped group of individuals free from many of the time or evaluative constraints of academic faculty. ⁴⁸

Our participants’ mixed sentiments about psychologist facilitators echo previous studies describing trainee hesitance in discussing workplace struggles with psychologists. While commonly cited barriers include stigma, licensure and confidentiality concerns, and judgment of colleagues, ⁴⁹ , ⁵⁰ , ⁵¹ participants in our study highlighted additional obstacles. Specifically, they expressed concern about psychologists’ inability to understand the specific stressors of their training environment. In order for psychologists to provide more effective facilitation and combat their “outsider” status, they should be pre‐briefed on major themes from peer group discussions and should be made intimately familiar with the specific characteristics and stressors of the residents’ workplace.

As a result of engaging in peer group discussions, both facilitators and residents noted an expansion of their social support networks. Given that social centrality may increase personal accomplishment and that loneliness is associated with greater workplace burnout, ¹ , ⁴ peer support groups may improve trainee wellness by cultivating a sense of belonging and fostering a deeper sense of meaning in the workplace. ³ , ⁶ , ⁵² As a sense of belonging allows residents to achieve their full potential and develop resilience, ⁶ , ⁵³ educators should ensure that residency curricula include formal protected opportunities for intimate peer‐to‐peer conversations that foster deeper inter‐class relationships. ⁶ , ³³ , ⁵²

Limitations

This was a single‐site study with a small sample size set at a large, safety‐net academic training program. Our specific workplace stressors may not be generalizable, and some training programs may lack the resources to identify and train alumni group facilitators.

CONCLUSIONS

Participants identified modifiable factors that enable and hinder effective peer support and offered insights into optimal models for group membership and facilitation. Our findings can inform the development of future wellness interventions aimed at encouraging medical trainees to discuss the challenges they face during their residency training.

The interview guide is available as Appendix S1.

CONFLICT OF INTEREST

The authors report no conflicts of interest.

AUTHOR CONTRIBUTIONS

AJ, JR, RT, and AV conceived the concept study and design. AJ, RT, JR, and AV acquired the data. AJ, RT, JR, AV, and JS analyzed and interpreted the data. AJ and JR drafted the manuscript. AJ, JR, AV, RT, and JS critically revised the manuscript for important intellectual content. AV, JS, and JR provided statistical expertise.

ETHICAL APPROVAL

This study was reviewed and deemed to be exempt by the University of Southern California Institutional Review Board (October 10, 2018; HS‐18‐00762).

Supporting information

Supplementary Material

Jain A, Tabatabai R, Schreiber J, Vo A, Riddell J. “Everybody in this room can understand”: A qualitative exploration of peer support during residency training. AEM Educ Train. 2022;6:e10728. doi: 10.1002/aet2.10728