As the healthcare landscape in the US becomes increasingly corporatized,1 bureaucracy is growing, and budgetary control and the locus of healthcare decision-making are moving farther away for the individual clinical practitioner.
For most of the latter half of the 20th century, healthcare decision-making, specifically decisions about direction, mission, and budget, were all significantly within the control of physicians and surgeons. Physician and surgeon autonomy has shifted radically over the past 30 years. Two noteworthy influences include a shift from private practice to employed physicians (70% of doctors are now employed), and the growth in corporate structures that have shifted the locus of decision-making, marginalizing physicians and limiting their ability to effect change.1
Increasing corporatization of healthcare clearly impacts the perceptions of surgeons and physicians. For instance, in a study of emergency medicine physicians, 70% agreed that the corporatization of healthcare has had a negative or strongly negative impact on both their job satisfaction and quality of patient care.1 A survey of emergency physicians demonstrated that as early as 2013, less than 50% felt “very comfortable” raising quality-of-care issues with hospital administration.2
Reduced decision-making authority in high-demand jobs has been shown to increase stress and burnout, which is a growing issue for surgeons. Numerous studies have demonstrated that symptoms of burnout, including emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment approach or exceed 50% among physicians.3-5 The demand for profit increasingly contributes to settings where physicians feel they cannot consistently meet patient needs and provide quality care, creating a sense of moral injury among providers.1,4
The diminished decision-making authority of physicians and surgeons has significant implications for their engagement, performance, and satisfaction. Substantial research also has documented that in high-demand jobs, the degree of control or decision latitude has important implications for both mental and physical health.6,7
High-demand and low-control (or decision latitude) jobs are associated with higher depression and death among workers, while high-demand and high-control jobs have a positive association with improved mental and physical health, particularly in high cognitive groups.
Perception of control is important in this context, as measures that either diminish or increase the perception of control, without altering actual control, can either exacerbate or mitigate this association. Thus, diminishing the perceived decision-making authority within the context of physicians’ highly demanding jobs directly increases mental stress, impacting overall burnout, well-being, and health.
Importantly, another factor has been shown to influence the association between job control and mental and physical health—the social support at work.6 Measures that promote internal solidarity and social support have been shown to mitigate the negative effects of low control. These data suggest that efforts to enhance social support among surgeons and physicians may reduce burnout and improve performance.
Therefore, investing in peer-to-peer coaching could reduce the stress and burnout among surgeons and improve surgeons’ ability to navigate an increasingly complex bureaucratic structure in order to successfully advocate for their patients.
Using Peer-to-Peer Coaching to Reduce Stress, Burnout
Coaching is effectively used to enhance performance in many high-performing professions such as athletics, business, music, and education.8 Coaching to improve technical and nontechnical skills in the OR, while a relatively recent development, has gained significant support, with systematic reviews demonstrating improvements in technical surgical performance.8 In fact, peer coaching can be used to enhance a surgeon’s ability to adapt to a changing healthcare environment, as well as reduce burnout because an essential aspect of effective physician coaching entails assisting practitioners to develop and deploy tactics and strategies that boost their actual and/or perceived sense of control and support when encountering workplace coping challenges.
Systematic reviews and meta-analyses demonstrate that interventions can significantly reduce measured rates of overall burnout, emotional exhaustion, and depersonalization, and that organizationally directed interventions have a larger effect than those that are physician-directed.9,10 In one cluster randomized trial, physicians in the intervention group had a significant reduction in burnout, and the interventions that improved interpersonal communication among providers and teamwork had an odds ratio of 3.1 (p=0.04) for improved job satisfaction.11
Several randomized trials have demonstrated that coaching delivered by either professional coaches or physicians who have received coach training improves burnout and resilience in both residents and practicing physicians and surgeons.12-14
In a randomized trial of 80 surgeons in which the intervention group received six monthly coaching sessions from professional coaches, the intervention group had a 5% reduction in burnout relative to controls and significantly improved resilience scores at the conclusion of the trial.12
In another setting, after receiving strongly positive feedback from participants of a professional development coaching program for interns,14 the program’s leadership subsequently undertook a randomized trial of coaching for residents. The randomized trial compared the effects on residents’ well-being as the result of two interventions. The intervention group received three coaching sessions over a 9-month period. Members of the control group were given electronic wellness resources. Coaching was provided virtually by attending surgeons who had undergone 3 hours of in-person training.
The intervention group showed significant improvement in burnout, work exhaustion, self-valuation, professional fulfillment, and well-being.15 In a more recently published randomized trial, 138 volunteers from the Massachusetts General Physicians Organization (MGPO) were randomly assigned in a 1:1 allocation to receive either early coaching or delayed coaching (control group) by trained physician peers.13 Participants underwent six coaching sessions over a 3-month period and self-selected their coaches from a pool of 13 peers who had undergone coach training. After the 3-month coaching period, researchers observed statistically significant improvements in burnout, interpersonal disengagement, professional fulfillment, and work engagement compared to the no-intervention group.
These findings are prompting organizations to implement peer-to-peer initiatives. For example, in response to their high rates of burnout and physician turnover, Envision Healthcare, a national hospital-based physician group, established a peer-coaching program that trained physicians who volunteered their time to learn the peer-coaching process. The trained physician peer coaches provided support to physicians who are at risk of burnout as well as supporting site directors. The program has resulted in increased resources to expand it. Additional referrals of physicians at high risk of burnout have been solicited, and the organization is recruiting additional physicians to provide support.
Another rationale for creating an internal, peer-to-peer coaching network relates to the ever-present need in today’s workplace to broaden and deepen a collaborative culture.
Peer-to-peer coaching creates structures and processes for social and professional support within the organization, enhances the listening, leadership, and development skills of those who undergo coach training, and strengthens connectivity across the organization’s medical staff structure. Coaching, in this context, is defined by the International Coaching Federation as partnering with a client in a thought-provoking and creative process that inspires them to maximize their personal and professional potential.
Coaching is a collaborative enterprise, in which the coach and client work together as equals to advance action-oriented goals. Coaching is an effective method to foster increased self-awareness and emotional intelligence, enhance psychological safety and trust within collaborative, multidisciplinary teams, and improve resilience and agility to navigate the ever-increasing pace of change. Coaching has been shown to enhance performance and, assuming a successful coaching interaction, may enhance the degree of perceived job control.16
The acquisition of coaching skills directly aligns with the qualities identified in highly effective listeners. In an analysis of data obtained to evaluate the performance of 3,492 managers engaged in a program to improve their coaching skills, characteristics that separated participants from the top 5% of listening skills were identified. The highest-rated listeners exhibited the following:17
- Asked questions designed to promote discovery and insight
- Made the conversation a positive experience for the other party by using phrases that offer support and convey confidence in the other person
- Engaged in cooperative conversations
- Provided nonconfrontational feedback that opened alternative paths to consider
Another justification for employing the peer-to-peer coaching model is the fact that physicians and surgeons often prefer support from colleagues more than support from nonphysicians. In a study performed at a Boston teaching hospital, 885 respondents from three different departments indicated they would prefer a colleague as a source of support.18 For physicians, peer coaching is an opportunity to talk with someone who understands the unique work culture, job responsibilities, opportunities, and trade-offs involved in the lives of medical professionals.16
Investing in developing coaching skills within an organization’s physician and surgeon groups should provide a strong financial return on investment through reducing burnout and its negative consequences, improving overall productivity, and supporting the development of a coaching culture within the organization.
The negative consequences of burnout are well chronicled. Burnout directly impacts an organization’s quality of care. It is associated with a two-fold increase in risk of medical errors and 17% increased odds of malpractice litigation.5 Burnout also significantly impacts the health of providers increasing the risk of alcohol abuse by 25% and doubling the risk of suicidal ideation.5
Burnout also is associated with lower patient satisfaction, reduced physician productivity, and higher physician turnover.3,19 In a longitudinal study of 2,500 physicians at the Mayo Clinic in Rochester, Minnesota, evaluating productivity through billing records, each 1-point increase of burnout on a 7-point scale, or 1-point decrease in professional satisfaction on a 5-point scale, was associated with a 30%–50% increase in likelihood of loss in productivity.19 The cost of turnover in historical studies is typically 2–3 times the physician’s salary, though it may be much higher if the potential loss in revenue is factored into the estimation.19
Considering these data, the cost of peer-to-peer coaching seems quite economically sound. The total cost per participant in the Kiser trial, including the training of 13 coaches, was $1,556.73.13 The ongoing costs for future participants (excluding training) would be $969.23. While creating a peer-to-peer network may have higher upfront costs than using external professional coaches, once physicians are trained, the ongoing cost is less. Comparing the ongoing cost of the MGPO peer-to-peer program to the Mayo program using external professional coaches, the peer-to-peer program cost is $430 less per participant.13
Long-term solutions for the challenges related to physician and surgeon well-being will require a multifaceted approach and an expansion of physician skills regarding self-care and promoting and maintaining collaborative teams. A dynamic physician peer-to-peer initiative can add value to such efforts.
At minimum, an organization launching a physician peer-to-peer process will create good will by demonstrating to team members that they are valued by the organization. The improved peer relations, heightened sense of unity and social support, and enhanced professional development in both those who receive coaching training and the clinicians who later are clients of the network will likely be added benefits from this investment.
