By Jordyn Feingold, MAPP and Annie Hart, MD
Several months ago, we were asked to write this blog post about PEERS, a well-being initiative we developed at Mount Sinai, and shortly thereafter our world was turned upside down by COVID-19 and the collective reckoning of systemic racism in our society. As a medical student and psychiatry resident physician working in New York City, we heard the word “helplessness” echo among healthcare workers, medical trainees, and patients alike as we grapple with enormous losses. And yet, in the face of fear and uncertainty, our community has found ways to move forward by connecting with one another, even in quarantine.
This ability to cope with adversity through social connection underlies the ethos of PEERS, a program aimed at bringing together medical trainees to reflect on common experiences, learn coping skills, and build community through structured support groups. During a time when our need for support is greatest and our access to human contact is most restricted, we have found creative ways to continue PEERS. We hope these learnings are helpful in supporting your institution’s medical trainees.
So what is PEERS?
The PEERS program (Practice Enhancement, Engagement, Resilience, & Support) is a trainee-led, structured, longitudinal program aimed at cultivating well-being, resilience, and community among medical trainees at the Icahn School of Medicine at Mount Sinai (ISMMS). The program is composed of discussion, mindfulness exercises, and evidence-based techniques from positive psychology and other therapeutic modalities.
Over the course of approximately 10 modules, the program targets challenges specific to each progressing stage of medical education and training to help equip learners with relevant skills to face adversity and thrive. Our program was initially developed for medical students as a schoolwide initiative, and over the past year we have adapted the program for graduate students and residents to address the needs of the trainees across disciplines and educational trajectories.
How has PEERS adapted in isolation?
In mid-March, when social isolation measures were implemented throughout our hospital system and society at large, it became clear that the in-person sessions we had planned would have to take place on a virtual platform. With a little creativity (mastering the art of the Zoom Breakout Room) and the incredible dedication of our PEERS team — medical students, psychiatry residents, and social workers who volunteer to facilitate groups — we were able launch the program online.
What types of PEERS sessions have taken place?
When isolation precautions began, medical students were pulled from the wards, classes were paused, and board exams were postponed, leaving students in a vacuum with the implicit message that their hard work was “non-essential.” In this space, the medical student body made itself essential — calling patients with COVID test results, delivering medications, sourcing PPE, offering childcare for house staff, serving fresh food to hospitals, staffing phone lines, and supporting our community in profound and unprecedented ways.
Within just a few short weeks of “work from home,” an entire class of third-year medical students logged onto Zoom with a small group of PEERS and facilitators for a session on dealing with stress. In talking about their respective experiences, it became clear that fear, anxiety, and anger, while experienced in very different ways, were feelings shared by all. Using a framework of basic Cognitive Behavioral Therapy (CBT) principles, students learned about the “pathophysiology” of anxiety (how an “activating event” triggers automatic thoughts that fuel behavioral, emotional, and physiologic consequences). We identified “thinking traps” — biases in our thought processes that can lead us astray — and wondered together what it means to “catastrophize” amid catastrophic times.
In another corner of the medical school, USMLE Step 1 exams were postponed and cancelled. In the pre-COVID era, this is a period of tremendous discipline, self-sacrifice, and often, isolation. With no test date in sight, students were left doing multiple choice questions in limbo; control over this meticulously planned process was suspended, and with it, a sense of personal agency. We again gathered on Zoom for a session called “Signature Strengths,” in which students appreciated their composite of unique character strengths in themselves and one another. It was a moment to step outside of clinical question stems, to look around at faces in the (Zoom) room, and celebrate each other.
In the words of one participant:
“Everyone was basically in happy tears the entire session, and it couldn’t have come at a better time to share and feel such appreciation for each other and ourselves. Even beyond taking note of and building on strengths, it was wonderful to be built up by one another today in the session and to reflect on, laugh about, and appreciate the past couple years together and how all of our friendships have evolved along the way.”
How does PEERS support both medical students and residents?
A core objective of PEERS is to thoughtfully and flexibly meet the needs of the different populations that we serve. Just as the experiences of residents differ from those of medical students, PEERS sessions take a different form when accounting for the clinical responsibilities of residency.
PEERS is currently operational in two residency programs. Sessions vary in terms of structure and timing, depending on availability and ongoing stressors. Some have been process-oriented through facilitated discussion, while others have incorporated planned exercises. Participation has varied from two facilitators with a single participant, to a single facilitator with 8-12 residents. We are finding that teaching these simple interventions and simply holding the space to build connection between co-residents can foster a sense of hope and solidarity.
How can focusing on the positive be helpful?
Human beings are hardwired to pay attention to potential threats for our survival, and this vestigial negativity bias is reinforced within the medical model as physicians are systematically taught to approach the world in a problem-focused way. Positive interventions are intentional acts aimed at bringing our attention to positive experiences with the same salience that we naturally have for negative experiences. The ability to hold the positive alongside the negative underlies resilience, the capacity to overcome adversity. In PEERS, we feature interventions that deliberately cultivate cognitive flexibility so that trainees can find meaning and even joy, alongside the rigor of medical training and other life stresses.
Importantly, this is not to minimize suffering or deny problems, particularly at a time when our society is experiencing collective trauma. Rather, the goal is to provide an additional lens on our daily lived experience – to notice, experience, and expand positive moments that might otherwise pass by unappreciated – in order to derive meaning from our daily lives. Being attuned to what is working, in addition to what is broken, can offer a productive stance to tackle very real problems, and experiencing positive moments even in the process of struggle gives us the strength to move forward.
How can your institution create something like PEERS?
Here are some of the steps that we recommend taking if you want to create a program like PEERS:
- Develop a team: Include students, trainees, and faculty who have a vested interest in student well-being; take inventory of what is already happening at your institution, and how a program like PEERS might fit in.
- Listen to your students & trainees: Conduct a needs assessment to hear from stakeholders what the challenges are, and what topics they’d most like to learn and talk about.
- Train group facilitators: Identify who at your institution might lead these sessions, based on availability, expertise, and the comfort of the participants.
- Carve out time: Work with your medical education teams, program directors, and/or other administrative personnel to carve out the time to deliberately focus on well-being practices.
- Pilot, iterate, evaluate: Have a session, gather feedback from participants and facilitators, and modify future sessions accordingly.
We have collaborated with Graduate Medical Education colleagues at Pittsburgh-based health provider and insurer UPMC to post four of our PEERS Sessions online as part of a new WELL Toolkit. Download these sessions and try them with your medical students or residents.
Now more than ever, we need spaces for medical professionals to come together — physically and virtually — to connect with one another, speak openly and vulnerably, and learn skills to process difficult. PEERS offers group-level positive interventions to help medical trainees do just that. Long before and well beyond the current pandemic, medical professionals deserve to be cared for, so we can feel relief, and even joy, in our every day.
Jordyn Feingold, MAPP is an MS4 at the Icahn School of Medicine at Mount Sinai applying into psychiatry. Annie Hart, MD is PGY-4 in psychiatry and chief resident at the Icahn School of Medicine at Mount Sinai. They are co-founders of the PEERS (Practice Enhancement, Engagement, Resilience, & Support) Program and Gold Humanism Honor Society members.