"I Wish They Had Asked": a Qualitative Study of Emotional Distress and Peer Support During Internship.

BACKGROUND: Interns are vulnerable to emotional distress and burnout. Little is known about the extent to which interns' well-being can be influenced by peer support provided by their senior residents. OBJECTIVE: To elucidate contributors to interns' emotional distress and ways that peer support from senior residents may impact intern well-being. DESIGN: Qualitative study using semi-structured interviews conducted December 2017-March 2018. PARTICIPANTS: Second year residents (n = 11) in internal medicine at a major academic medical center during the data collection period. APPROACH: Constructivist grounded theory approach in which transcripts were analyzed in an iterative fashion using constant comparison to identify themes and to create a conceptual model. KEY RESULTS: The investigators identified three themes around emotional distress and two themes around resident peer support. Distress was a pervasive experience among participants, caused by a combination of contextual factors that decreased emotional resilience (e.g., sleep deprivation) and acute triggers (e.g., patient death) that led to an abrupt increase in distress. Participants grappled with identity reconciliation throughout internship. Reaching clinical competency reinforced self-efficacy for participants. With regard to peer support, participants recalled that resident support was ad hoc, primarily involving task support and debriefing traumatic events. Participants reflected that their intern experiences shaped their supervisory support style once they became senior residents; they did not perceive any formalized, systematic approach to supporting interns. CONCLUSIONS: We propose a model illustrating key points at which near-peers can make an impact in reducing interns' distress and suggest strategies they can use. Given the substantial role peer learning plays in intern development, senior residents can impact their interns by normalizing emotions, allowing vulnerability, and highlighting the importance of self-care. A formalized peer support skill-building curriculum for senior residents may empower them to provide more effective support as part of their supervisory efforts.

Peer Support Ambassadors: A Program to Advance a Supportive and Inclusive Clinical Learning Environment.

ABSTRACT: Peer support is beneficial to physicians in distress, but few institutions have created formal programs that train residents and fellows to effectively support their peers. Existing curricula also do not address the differential experience of residents from historically excluded groups, who are more likely to experience distressing mistreatment and discrimination in the clinical learning environment. The Graduate Medical Education (GME) Peer Support Ambassador (PSA) Program aimed to address this gap by: (1) offering peer support skills and trauma-informed care training to a diverse cohort of resident leaders representing a range of specialties, (2) deploying these leaders to support their peers, and (3) facilitating opportunities for participants to train other residents in these skills. In the PSA program's inaugural year, 10 residents were trained in fundamentals of peer support, trauma-informed care, and the restorative mindset. The training increased participants' confidence and skills in these areas, increased their understanding of when to refer a co-resident for additional levels of support, and their awareness of resources for mental health care and addressing mistreatment and discrimination. Beyond the skills training, the program broadened participants' perspectives about other residents' experiences and helped them feel more connected to residents in other specialties. Opportunities to improve the PSA program include creating more opportunities for program participants to connect between sessions and after the training, publicizing the program more effectively to residents experiencing distress, and training a larger number of residents in peer support skills.

Lichen sclerosus in a breast cancer survivor on an aromatase inhibitor: a case report.

Lichen sclerosus is a commonly misdiagnosed disease that is characterized by thinned, hypopigmented, crinkled skin that often forms a figure-eight shape around the vaginal and anal openings. We present a case of advanced lichen sclerosus in a 53-year-old female patient prescribed a nonsteroidal aromatase inhibitor after the excision of a breast cancer tumor. We present a diagnostic approach to lichen sclerosus by recognizing its common figure-eight pattern, and we review the known causes and treatment of lichen sclerosus. Research has shown that lichen sclerosus is more common in low estrogen states, and thus it is logical that aromatase inhibitors could increase a patient's risk for developing this disease. We therefore propose that all patients prescribed aromatase inhibitors undergo regular vulvo-vaginal exams to rule out lichen sclerosus and other hypoestrogen-related vulvo-vaginal problems.