By Caitlin Krol and Ivory Shelton
Serendipity (n): the occurrence of events by chance in a happy way.
The inspiration to develop a peer support program for students at Wake Forest School of Medicine arose through pure serendipity: a chance conversation over dinner between two struggling roommates in our third year of training.
While we silently battled compassion fatigue, believing our feelings of inadequacy were unique, we finally opened up about our feelings one evening across the kitchen table. We wondered if our peers shared our frustration. Why weren’t there more resources for trainee burnout? Were we “bad students” for feeling cynical? What was this so-called devil in the third year?
Turns out, we weren’t alone in our feelings at all. In fact, once we spoke openly with each other, we found that more and more students felt similarly. But with the student experience largely absent in the literature, most of us were moving through medical school feeling isolated in our pain.
In the spring of 2019, we decided to transform our individual struggle into collective healing. With $500 and support from the Wake Forest School of Medicine Gold Humanism Honor Society Chapter, we piloted Compassion Coaches, a peer-led program for third-year students that allows them to safely debrief emotionally intense experiences and build community through vulnerability and reflection.
Prior to kicking off the initiative, we designated a leadership committee of five individuals to manage logistics such as space and food, provide training to coaches, and recruit outside experts—including faculty with crisis experience—to serve as content advisors and support participants if conversations became triggering. Ten coaches were also recruited to facilitate small group discussions. Coaches came from the Gold Humanism Honor Society or were fourth-year students, and all received training in group facilitation, as well as materials, scripts, and other guidance to foster success.
Compassion Coaches sessions took place once each trimester in tandem with a week of activities third-year clinical classes participate in to prepare for their next core rotation. With faculty backing, a two-hour block was set aside for the session, limited to students only. Sessions began with a light program over lunch, after which students moved to private classrooms in groups of 8-10, each with an assigned coach.
Small groups started with icebreakers and norm-setting activities to create a psychologically safe space to be vulnerable. From there, conversation was either organically guided or prompted with questions such as: “Has the culture of medicine surprised you?” or “How have social determinants of health shaped your perceptions of patient populations?” Conversation then flowed freely for up to an hour, with coaches facilitating equitable contributions from all students. As the group ended, students reflected on three questions: how they hope to practice at the attending level, how they can support their peers’ growth and wellbeing, and how the program can be improved.
Following each session, all participants took a survey about their experience that evaluated the quality of the session, the continuation of the program in coming years, and ways to enhance content and program structure. Coaches also completed the questionnaire, with the addition of questions related to themes that emerged in their groups.
Pilot Program Results
As with most pilot programs, our findings offer fascinating insights about the experience of medical school training, as well as the effectiveness of peer support programs like Compassion Coaches.
First, participant evaluations underscored how much students enjoyed the experience of peer support. In fact, 100% of coaches expressed a desire that the program continue. Among participant respondents, 94.6% indicated that the program was both enjoyable and should be continued. One student stated that the program “was an important reminder for many of us…that we all struggle sometimes and should strive to support one another.”
Coaches cited both “helplessness within hierarchy” and “isolation and disconnection” as prevailing themes in their groups. The first of these themes regularly arose, manifesting as disempowerment among students; third-year students are seen as the “lowest level” of the clinical hierarchy and thus feel unable to advocate for themselves or their patients. Even when students do speak up, they exhaust limited mental and emotional energy (and capital) while they navigate appropriate timing, articulation, and the nuances of health inequity, all at the risk of not being heard or being evaluated poorly as a result of their outspokenness.
Feedback on the second theme of isolation and disconnection stems from unpredictable schedules, physical and emotional fatigue, and an unspoken expectation to be engaged, prepared, and “on” at all times. As one student reflected, “I feel like I’ve been performing for a never-ending dinner party everyday for the past 12 months.” Additionally, survey responses indicated that students don’t share their experiences with peers because they struggle with feelings of mediocrity.
Overall, the program leadership team was struck by the pilot’s overwhelmingly positive impact, and the open and honest communication it nurtured. The systemic stressors we previously struggled to name in our own isolated endeavors were echoed many times by participants when granted the time, space, and community within which to speak.
As we move beyond simply identifying challenges to proactively seeking solutions to bolster trainee well-being, we offer the following recommendations for the future of the program.
First, more coaches need to be recruited to afford smaller breakout groups for successful peer support initiatives. End-of-session handouts should also include clerkship contacts, mental health and wellness resources (including counseling or spiritual services), and contacts for serious concerns.
Second, to address pervasive feelings of disempowerment, we’re partnering with the Office of Diversity and Inclusion and our Chief Diversity Officer to implement training for individuals who experience or witness unhealthy or discriminatory interactions. From the initial conversation, Chief Diversity Officer Dave McIntosh showed energy and enthusiasm, stating that this training has been completed by administrative leadership at the highest level, but that this forum was an incredible opportunity to reach medical trainees on the front lines. “Our hope is that such a partnership will provide students with tools and recourse when confronted with disempowering situations,” he shared.
Finally, to address feelings of isolation and disconnection, we’re launching a series of community dinners that provide informal monthly gatherings for students to discuss experiences and build connections among peers. We’re partnering with Elizabeth Métraux, lead author of Better Together: A Guide for Bringing the Power of Community into your Clinics, as well as the Office of Philanthropy, the Office of Student Affairs, and the Gold Humanism Honor Society to secure funding and seamless transition of planning.
Overall, we have been humbled by our experience developing, delivering, and reflecting on the pilot Compassion Coaches program, and look forward to strengthening peer support within our own clinics as we practice medicine outside of the confines of medical school. We’re also thankful to our peers and colleagues for their participation, honesty, and hard work; to our faculty advisors and mentors for their advice and support; and to our institutional leadership for their eagerness to improve the climate of medical education as we cultivate a generation of clinicians who are fulfilled, connected, and heard.
It takes a diverse community to “look the devil in the eye” and to no longer leave positive change to serendipity.
Caitlin Krol is an MD Candidate 2020 from the Wake Forest University School of Medicine and will be completing her residency training at UC San Diego. She is the Class of 2020 Representative for the school’s Undergraduate Medical Education Curriculum Committee. Ivory Shelton is an MD Candidate 2020 from the Wake Forest University School of Medicine, and will be completing her residency training at Vanderbilt University. She is the President of the Wake Forest Chapter of the Gold Humanism Honor Society.