Mentoring, coaching and peer-support programs promoting well-being for physicians: A systematic review

Mark R Ellis*¹, Gwen Wilson², Esme Nulan¹, Margaret A Day², Jane A McElroy²

1. School of Medicine-Springfield Clinical Campus, University of Missouri-Columbia, Columbia, Missouri, United States of America
2. Department of Family and Community Medicine, University of Missouri-Columbia, Columbia, Missouri, United States of America

* [email protected]

OPEN ACCESS

PUBLISHED: 30 September 2024

CITATION: Ellis, MR., Wilson, G., et al., 2024. Mentoring, coaching and peer-support programs promoting well-being for physicians: A systematic review. Medical Research Archives, [online] 12(9). https://doi.org/10.18103/mra.v12i9.5618

COPYRIGHT: © 2024 European Society of Medicine. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

DOI https://doi.org/10.18103/mra.v12i9.5618

ISSN 2375-1924

ABSTRACT

Introduction As many as half of U.S. physicians experience impactful levels of burnout. In early-career physicians, the consequences of burnout are significant with linkage to poor professionalism and patient care. A nurturing peer community and physician mentoring may mitigate against burnout and its associated sequelae; however, such programs for early-career physicians are rare and their impact largely unknown. We aim to synthesize the current literature on the impact of longitudinal mentoring and coaching programs for physicians.

Methods The authors searched four bibliographic databases to conduct a systematic review following PRISMA guidelines. Included studies were published between 01 January 2000 to 30 October 2022 and peer-reviewed articles reporting original research. The review examined associations between either a career mentoring, coaching, or peer support theme and outcomes in the career path of physicians.

Results Review of 5528 records yielded 23 articles that met inclusion criteria, with about half describing U.S. programs and half completed since 2017. Of these, 14 studies were of “high” or “medium” quality, 7 studies involved primary care physicians and 3 studies focused only on early-career physicians. In mixed methods studies, participants consistently reported positive experiences from their mentorship involvement and the 8 randomized control or cohort studies also reported positive effects with the mentoring programs.

Conclusion Rigorous data supporting the value of mentorship, including the best approach to be used (coaching, mentorship, or peer support) is lacking. However, a growing database of quality studies affirms physician mentoring as important to physician retention, wellbeing and quality healthcare delivery.

Keywords

• Mentoring
• Coaching
• Peer-support
• Burnout
• Physician well-being

Introduction

Over 40 years ago, Maslach and Jackson defined burnout as “a syndrome of emotional exhaustion and cynicism that occurs frequently among individuals who do ‘people-work’ of some kind. A key aspect of the burnout syndrome is increased emotional exhaustion which is related to job satisfaction, performance and retention.” Although the syndrome was named over 40 years ago, this phenomenon has been a focus of intensive research. Studies have linked feelings of burnout to adverse mental health issues among healthcare providers and to compromised healthcare for their patients. Working in healthcare is increasingly demanding. Studies completed in the last two years report a burnout rate of forty to fifty percent among U.S. Physicians. Nearly one-quarter of these are planning to leave medical practice within two years. Burnout is reported by 24% to 75% of resident physicians and may increase during the first year of practice. These declining trends in job satisfaction have also been reported among British and Norwegian general practitioners. This is of particular concern during the first five years of practice, wherein high demands and lack of professional resources result in lack of engagement, withdrawal behaviors, and harms to personal health.

Numerous studies have identified predictors of burnout, such as use of electronic medical record, poor work control and greater time pressure. This has led to multiple suggestions to reduce the factors associated with burnout, with much less attention given to programs to support well-being among healthcare clinicians. Coaching, mentoring, and peer support each have potential to enhance well-being. Mentorship, in which a more experienced and knowledgeable healthcare professional guides a less experienced colleague in career development, has been utilized since the dawn of medical practice. It requires an ongoing relationship between the mentor and one who is being mentored. Peer support—the sharing of experience, knowledge, and a social network among individuals of equivalent experience and a common background − is a close cousin of mentorship. Coaching, a process of inquiry, encouragement, and accountability, seeks to increase self-awareness and to facilitate a person’s navigation of professional life and career choices. It does not require the person and his/her coach to share a professional background.

The recent epidemic of physician burnout-especially in young and mid-career physicians-has led to a proliferation of related commentaries and small mentorship studies. What has been lacking is a cogent compilation and overview of this body of research. We sought to examine the impact of longitudinal coaching mentoring, and peer support programs for physicians.

Methods

Our systematic review follows the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 guidelines. We performed a comprehensive search of four bibliographic databases: PubMed, CINAHL, Scopus, APA PsycINFO with PsycARTICLES for studies published in English between 01 January 2000 and 30 October 2022. The initial search was conducted on 30 June 2022 and last updated on 30 October 2022. We restricted our search to articles focused on physicians, with emphasis on mentoring, coaching, or peer support programs. Sample search terms utilized were physician, doctor, hospitalist, mentor, coach, orientation, onboarding, retention, burnout, stress, resilience.

Eligible publications included either mentoring or coaching intervention programs for physicians, excluding studies with the objective of developing specific clinical skills. We included only studies of physicians who had completed training. We excluded systematic or narrative reviews, program overviews, conference abstracts, opinion pieces, and protocols. Screening was performed using Rayyan, a freely available online screening tool. Two reviewers conducted independent blinded screening on title and abstract. After the initial independent decisions, two reviewers met to review records with conflicting decisions. The full text review was screened by one reviewer, and any uncertainties discussed with a second reviewer.

DATA EXTRACTION AND QUALITY ASSESSMENT

We created a data extraction table to gather data on objectives, interventions, length of intervention, participants, settings, outcome, instruments, and key findings. Data extraction was performed by one reviewer and verified by a second reviewer. Quality assessment was measured by study type (quantitative, qualitative, or mixed methods). We assessed quantitative studies using the National Heart, Lung, and Blood Institutes’ study quality assessment tools, based on the study methodology. We assessed qualitative studies using the Critical Appraisal Skills Programme (CASP) Qualitative Checklist. Mixed method studies were assessed using both quality assessment tools and the average reviewer rating. Two reviewers independently rated each study; conflicting ratings were discussed to reach consensus.

Results

STUDY SELECTION

As shown in Figure 1 once duplicates were removed, 5528 records were screened based on title and abstract. After the initial screen, we reviewed 297 full text articles. The most common reason for full text article exclusion was wrong outcome (n=3593) which included both lack of outcomes (i.e., commentary) and clinical outcomes (i.e., surgical procedure). Among the 297 articles, 23 articles met our inclusion criteria.

STUDY CHARACTERISTICS

Nearly half of the 23 selected articles described U.S. programs and were completed after 2017. Nine studies reported participants’ age; in six of these, the majority of subjects were aged 50 or less (Table 1). Participants’ average years since training, recorded in ten studies, ranged from 2.5 years to 20 years post-residency (Table 2). Thirteen studies recorded neither the age of participants nor their number of years in practice. Although thirteen studies reported a male/female gender breakdown, only three of 23 studies recorded race or marital status data (Table 1). Nine studies involved general practitioners, family physicians, or other primary care physicians and three studies focused on early-career physicians. The number of participants ranged from 9 to 525 with all but four studies occurring within the last decade. Fourteen studies were of “high” or “medium” quality,” based on established quality ratings tools (Table 3). Only six studies used an experimental design, whereas others used a post-intervention survey, cross-sectional survey, or qualitative interviews.

In our review, of the 18 studies that evaluated interventions, 7 were about coaching, 8 mentorship, and 3 peer support. Coaching involves inquiry, encouragement, and accountability to increase self-awareness, motivation, and the capacity to take effective action. Coaches do not need to be physicians or be directly involved in health care. Professional coaching can be tailored to focus on the aspects desired by recipients and can assist individuals in their effort to navigate their professional life, their choices, and the direction of their career. Mentorship is characterized by a relationship in which one individual who is more knowledgeable and experienced guides a less knowledgeable and less experienced individual; it may involve physicians or other individuals with direct experience in the health field. Peer support denotes collegiality among and support from peers. It involves the sharing of knowledge, experience, and emotional and social support between individuals who have common experiences. It is an informal relationship between colleagues.

Of the studies that evaluated interventions (n=18), eleven were ranked high-or medium quality, three employed qualitative or mixed methods design and eight quality studies utilized randomized controlled trial or prospective cohort design. Interventions employed in these studies included onboarding for new physicians, professional or positive psychology coaching sessions, a cognitive behavioral coaching retreat followed by online sessions, junior-senior faculty dyad mentoring using suggested topics, and physician mentoring or coaching provided through health system leadership. Group interventions included small group sessions led by trained physician facilitators, facilitated small group sessions for RNs and physicians lead by various health professionals, a single evidence-based workshop with a follow-up on-line program, and physician small group sessions utilizing a guideline but without a trained (physician) leader.

Five of the included studies used structured core content for mentoring or coaching activities. Key mentoring topics included optimizing meaning in work, integrating personal and professional life, building social support and community at work, improving work efficiency, addressing workload, building leadership skills, pursuing hobbies and recreation, engaging in self-care, and strengthening relationships outside of work. Those studies that utilized a guided program also focused on identifying a vocational purpose and personal strengths, building effective work teams, and dealing with stressors; or on dealing with differences or conflict, medical error, and giving feedback in challenging circumstances. Qualitative studies stressed the importance of boundary-setting and prioritization, self-compassion, and self-awareness among physicians who were being mentored.

Tools used during mentoring/coaching sessions included positive psychology (reframing negative situations, goal setting, simulation of work-related scenarios, mindfulness tools, reflecting on experiences that have brought joy, gratitude tools) and use of validated strengths-based tools (Best-self Tool, Values in Action Assessment, Using Strengths in New Ways Tool).

Three high- or medium-quality studies did not utilize interventions but provided useful perspectives on coaching and mentoring. Gordon et al. studied twenty recent UK medical graduates over six to nine months, performing content analysis of audio-diaries. Respondents identified having a senior colleague as an informal mentor and having peer support as key factors that eased the transition to clinical practice. Saperstein et al. performed a cross-sectional study of 186 Navy family physicians, finding a positive association between having a mentor and job satisfaction. Sekerka et al.’s qualitative study of thirteen family medicine faculty focused on the benefit of coaching to the coaches themselves. The key informants expressed that serving as a peer coach encourages times for reflection and learning and has benefit to personal and professional development.

Nine studies were rated as lower quality studies. This was based on limitations of sample size, unrecorded demographic factors, choice of methodology, or methodologic flaws, but each study was nevertheless instructive. These studies included a qualitative/post-intervention survey of senior United Kingdom mentors (N=151) of junior physicians, a post-intervention survey for new radiation oncologists (N=9) who had completed an onboarding mentorship program, a cross-sectional survey of early-career Canadian family physicians (N=525) exploring respondents’ perceived mentorship needs, a small randomized controlled trial comparing 1:1 and group mentoring for UK physicians with self-identified mentorship needs (N=14), and a post-intervention cohort survey to study the impact of mentoring on participants’ patient experience scores (N=16). Additional lower quality studies used post-intervention or cross-sectional survey methodology to evaluate new physician mentorship programs, to analyze the content and perceived value of a “women in Emergency Medicine” mentorship program, and report the use of a mentorship checklist for new physicians.

Of the studies that evaluated interventions (n=18), eleven were ranked high-or medium quality, three employed qualitative or mixed methods design and eight quality studies utilized randomized controlled trial or prospective cohort design. Interventions employed in these studies included onboarding for new physicians, professional or positive psychology coaching sessions, a cognitive behavioral coaching retreat followed by online sessions, junior-senior faculty dyad mentoring using suggested topics, and physician mentoring or coaching provided through health system leadership. Group interventions included small group sessions led by trained physician facilitators, facilitated small group sessions for RNs and physicians lead by various health professionals, a single evidence-based workshop with a follow-up on-line program, and physician small group sessions utilizing a guideline but without a trained (physician) leader.

Five of the included studies used structured core content for mentoring or coaching activities. Key mentoring topics included optimizing meaning in work, integrating personal and professional life, building social support and community at work, improving work efficiency, addressing workload, building leadership skills, pursuing hobbies and recreation, engaging in self-care, and strengthening relationships outside of work. Those studies that utilized a guided program also focused on identifying a vocational purpose and personal strengths, building effective work teams, and dealing with stressors; or on dealing with differences or conflict, medical error, and giving feedback in challenging circumstances. Qualitative studies stressed the importance of boundary-setting and prioritization, self-compassion, and self-awareness among physicians who were being mentored.

Tools used during mentoring/coaching sessions included positive psychology (reframing negative situations, goal setting, simulation of work-related scenarios, mindfulness tools, reflecting on experiences that have brought joy, gratitude tools) and use of validated strengths-based tools (Best-self Tool, Values in Action Assessment, Using Strengths in New Ways Tool).

Three high- or medium-quality studies did not utilize interventions but provided useful perspectives on coaching and mentoring. Gordon et al. studied twenty recent UK medical graduates over six to nine months, performing content analysis of audio-diaries. Respondents identified having a senior colleague as an informal mentor and having peer support as key factors that eased the transition to clinical practice. Saperstein et al. performed a cross-sectional study of 186 Navy family physicians, finding a positive association between having a mentor and job satisfaction. Sekerka et al.’s qualitative study of thirteen family medicine faculty focused on the benefit of coaching to the coaches themselves. The key informants expressed that serving as a peer coach encourages times for reflection and learning and has benefit to personal and professional development.

Nine studies were rated as lower quality studies. This was based on limitations of sample size, unrecorded demographic factors, choice of methodology, or methodologic flaws, but each study was nevertheless instructive. These studies included a qualitative/post-intervention survey of senior United Kingdom mentors (N=151) of junior physicians, a post-intervention survey for new radiation oncologists (N=9) who had completed an onboarding mentorship program, a cross-sectional survey of early-career Canadian family physicians (N=525) exploring respondents’ perceived mentorship needs, a small randomized controlled trial comparing 1:1 and group mentoring for UK physicians with self-identified mentorship needs (N=14), and a post-intervention cohort survey to study the impact of mentoring on participants’ patient experience scores (N=16). Additional lower quality studies used post-intervention or cross-sectional survey methodology to evaluate new physician mentorship programs, to analyze the content and perceived value of a “women in Emergency Medicine” mentorship program, and report the use of a mentorship checklist for new physicians.

Discussion

Previous systematic reviews evaluated the prevalence of burnout in physicians, presented evidence that burnout is associated with safety-related quality of care and explored physicians’ perspectives about organizational, contextual, relational and individual factors that mitigate against burnout. Meta-analyses have affirmed the importance of organization-directed and physician-directed burnout interventions, including psychosocial skills and mindfulness training for physicians. In contrast, limited studies have explored strategies to improve satisfaction and well-being for physicians that address organizational or system factors. Our systematic review has uncovered more than a dozen quality studies that, taken together, clearly demonstrate the value and promise of mentoring/coaching/peer group meetings in enhancing physician wellbeing. However, it is difficult to draw conclusions or make recommendations based on these 23 studies due to their heterogeneity of the purpose, design, and outcomes. Of special concern is the issue of the early-career physician. Although we initially focused our review on this population alone, we found only three relevant studies of early-career physicians. The narrowness of Lin et al.’s prospective cohort (junior faculty mentees from a single specialty) limits the application of that study’s findings. The qualitative methodology of Hernandez-Lee et al. and Gordon et al. is exploratory rather than definitive. And yet, given that over a quarter of early career physicians report burnout, a strong mentoring focus for early career physicians seems vital. Sparse information was provided on study participants’ characteristics. Specifically, half of the studies provided information on number of years in practice and only three reported the proportion of time the participants engaged in direct patient care. Similarly, only three studies indicated the race of participants, about one third indicated age and half indicated sex. Absence of this information limited a more comprehensive understanding of this topic.

Cordova et al. has proposed a developmental model for physician resilience training, beginning in the preclinical years and extending throughout the physician lifecycle. The model affirms attentional practices including mindfulness; the necessity of healthy lifestyles and behaviors; the importance of building safe and diverse workplaces; the value of reflective practice and conflict management. It underscores the need to lead clinical teams well, to give and receive feedback, to recognize and address burnout, and to transition to a role in advocating policy and systems change. Shanafelt and Noseworthy have outlined organizational strategies to promote physician engagement and prevent physician burnout. Their nine strategies include emphases on harnessing the power of leadership, cultivating community at work, promoting flexibility and work-life integration, and providing resources to promote resilience and self-care. Our systematic review’s studies complement Shanafelt and Noseworthy’s work by including a variety of employable, effective 1:1 and group strategies for physicians, but these require institutional support and funding. At issue are several key questions for system leaders and researchers: How will the healthcare system balance financial outlays necessary for programmatic support with future perceived gain? Are less costly interventions such as formalized and approved peer group meetings effective enough to justify their widespread use, and when should more costly but possibly more effective formal mentoring and coaching interventions be employed? Clearly, more study of and emphasis on peer coaching and senior-junior partner mentorship, employed especially for new physicians, is needed to answer these vital questions.

Conclusion

Rigorous data validating the value of mentorship, including the best approach to be used (coaching, mentorship, or peer support) is lacking. However, a growing database of quality studies, sufficient to justify additional studies of mentoring in early- and mid-career physicians, affirms physician mentoring as central to physician retention and wellbeing. Although sparse evidence supports one particular type of program over another (i.e., coaching, mentoring, or peer group support), each one of these programs, as described in this systematic review, reported positive outcomes. The trifecta for effective healthcare encompasses improved care for the patient, better population health, and reduced healthcare costs. Given the overwhelming evidence of mental ill-health, burnout, and reduced retention among healthcare professionals, all three of these goals rest on improving well-being, satisfaction and flourishing among healthcare professionals and instituting a well-being program can aid in that endeavor.

Conflict of Interest Statement

The authors declare no conflicts of interest.

Acknowledgements. This study was performed in collaboration with the CoxHealth (Springfield, MO) and University of Missouri Rural Health Research Center.

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