Peer Consultation Builds Camaraderie, Expertise

When Colorado psychiatrist Ann Seig, M.D., wrestled with erotic transference and countertransference issues, she didn't have to struggle alone. Seig's feeling of "stark terror" signaled "a need to talk to someone" about this troublesome case. She brought her concerns to her peer consultation group, where colleagues helped her discern how issues in her private life were contributing to the countertransference.

"They had wonderful, supportive and therapeutic guidance to give," said Seig, who has been a member of the all-woman group for five years. "I trust this group with my life...It has saved [me]."

Seig is among the countless-and uncounted-number of psychiatrists who meet regularly to receive and provide feedback on cases. Peer consultation or peer supervision, often referred to as the curbside consult, has long been a mainstay of continuing clinical education for many psychiatrists, said Leon Hoffman, M.D., chair of the committee on public education for the American Psychoanalytic Association. It can take the form of spontaneous interactions in hospital hallways and cafeterias, and it is alive and well in regularly scheduled discussions held over potluck dinners.

"Whatever breaks the isolation of psychotherapy probably is a help," said Los Angeles psychiatrist Ronald Mintz, M.D. "While there may not be a great deal of one-on-one structured supervision in the years beyond training, I think there are a lot of opportunities, and they have been increasing."

Unlike legally mandated peer review, peer consultation involves the informal assembly of colleagues to discuss cases. Information that is shared among group members remains confidential, creating an atmosphere of trust and openness that deepens the relationships of group members-many of whom met during residency.

"It has been a wonderful experience, both professionally and personally," said Hillel I. Swiller, M.D., clinical professor of psychiatry and director of the division of psychotherapy at Mount Sinai Medical Center in New York City. "This kind of thing, when it works well, is immensely gratifying and supportive, and I recommend it to everyone. You should be blessed with good colleagues."

Swiller counts himself among those blessed. The New York analyst has been in the same seven-man peer group for 25 years. His involvement in the group has helped him chart the course of his own professional and personal evolution, as well as that of his colleagues. When they first began meeting, Swiller said, they "were kind of rigid in terms of a traditional analytic stance." However, from their discussions and with the support of the group, they now "do and say things to patients that would've horrified our supervisors." When asked what types of issues they currently discuss, Swiller replied, "we're more open to psychopharmacology and much more open to couples, group and family therapy."

Swiller said the close bonds that have developed between group members enable them to quickly and accurately pinpoint countertransference issues. "Because we know each other so well, we can help each other," he said. "We're ready to talk about the feelings our patients generate in us and are open to listening to what our colleagues have to say."

Group members, whose areas of expertise include forensics, adolescent psychopathology, group therapy and residency training, readily refer patients to one another, he added.

The ages of the men in Swiller's group range from 58 to 71 years old. Like their peers in Colorado, Swiller said they unintentionally formed and maintained a single-sex group. He added that obtaining generational heterogeneity would represent far more of a challenge than integrating female members. "What would a 30-year-old make of our talking about grandchildren all the time?" he asked.

Helen Horowitz, M.D., said her Colorado-based psychiatric peer consultation group, which she shares with colleagues Seig, Dewey Walker, M.D., and two others, eases the isolation of private practice. Asked about her experiences in an exclusively female group, Horowitz said she believes group members have been more willing to include discussion of their personal lives than they might be if the group were mixed.

Horowitz clearly recalls the emotional support and concrete help she received from fellow group members during one particularly harrowing experience. A relative of one of Horowitz's bipolar patients located Horowitz at a peer consultation dinner meeting to inform her that the patient had visited her office earlier that day with a gun.

"The group worked with me...to figure out what steps I needed to take, including calling some high profile psychiatrists to bounce ideas off," she said. Group members also helped Horowitz draft a letter of termination and formulate a plan to have the letter delivered to the patient, who had been jailed that day in an unrelated matter. "It is just the most valuable professional activity," Horowitz said. "I put it first over anything else...We save each other."

Horowitz also believes that their peer consultation group is profoundly and positively affected by the absence of the power dynamics inherent in traditional supervision. "Here, we're all equals," she said. "We each have value that may be different but is of equal strength. There's no concern about being evaluated poorly...When you're working with one supervisor, they have one perspective and one opinion. We agree to disagree, and we respect each other's opinions and the differences between them."

Seig said the group, which meets twice each month to discuss cases over dinner, is an important way for psychiatrists to receive needed feedback and support. "One of the banes of our profession is that, as health care professionals in charge of other people's mental health, there's not more of an emphasis on our [own] mental health," Seig said. "Even though people give lip service to our mental health, there are very few ways that we're taught about how to take care of ourselves. We're left to our own devices."

Seig urges clinicians to pay attention to "that feeling of discomfort or unease" as a sign to review the treatment process and get help if needed, particularly around issues of countertransference. Peer supervision is not easy to work into a hectic schedule, said Seig, but "it's well worth the time...Every minute you spend with your peer supervision group is worth its weight in gold." She added, "I know my peer supervision group knows what I'm talking about because they've been there. It can be joyous, heartwarming and liberating."

Seig, who has been in private practice for eight years, said she is committed to instilling the concept of self-care in the residents she supervises. "If you're not taking care of yourself, you can't take care of someone else adequately," she explained.

Massachusetts psychiatrist Bob Welch, M.D., chief of psychiatry at Tewksbury Hospital, said peer consultation enables him to openly discuss topics that he might feel uncomfortable sharing with a supervisor or subordinates. "We've known each other since we were second-year residents, and we've seen each other in our weak and ignorant moments so you don't have to pretend," he said. He added that while there are plenty of opportunities to seek advice in a state hospital setting, such opportunities are not as available to solo practice professionals. However, peer consultation offers the unique chance to get objective feedback from colleagues who are outside the system and can offer fresh and diverse perspectives. Group members collectively have expertise in child psychiatry, dialectical behavioral therapy, electroconvulsive therapy and business issues.

Welch and other participants also believe that peer consultation is an easy and useful way to trade information on prescribing medications. "I tend not to use new drugs until I get a sense of things from people I trust who are using them," he said. Adds New York analyst Hoffman, "You can hone up on your [medication] skills in ways you couldn't get from going to a lecture or a textbook."

Indeed, Hoffman calls peer consultation "the epitome of continuing medical education" because it enables psychiatrists "to address countertransference issues in a way that nothing else can...The other person can hear and see things that you yourself may not be able to see clearly. It's much easier to see things in others than to see them in yourself."

For example, Hoffman said his fellow group members helped him recognize how his own issue with competitiveness was contributing to a treatment impasse. "That's when analysts and therapists get in trouble, when people think they're trying to do something in the patient's interest but, in reality, it has to do with themselves."

New York City psychoanalytic graduate Lisa Korman, M.D., has participated in a peer consultation group for three years. Like Hoffman, she feels that practitioners who close themselves off from different points of view are most likely to get into difficulty with their patients. She also believes that uncertainty is a core element of work in the field. "I think people who are willing to discuss their work with colleagues, in general, are trying to preclude making some sort of mistake," Korman explained. "You're more likely to get into trouble when you think you're sure about something."

Peer consultation is a valuable, proactive way to get help with a difficult case, explained Walker. "I don't have to get into deep trouble before I get a consultation. This meeting every two weeks allows me to discuss cases that haven't reached that point yet."

Walker said the group also has been helpful in ascertaining constructive ways to deal with managed care conflicts and other professional practice issues. "We really depend on each other," she said. Walker recently asked group members to review a draft of a letter she wrote to a managed care company. "I have a tough patient to take care of and a managed care company that wants to micromanage me," she explained. "I have some anger about this managed care company, and I don't want the letter to reflect that anger or be emotional because that doesn't have a place."

Swiller said in his group members also talk about private practice issues, and they value being at similar stages in their lives professionally as well as personally. Sometimes conversations happen over "official" group dinners and sometimes on shared vacations.

"I think we're all working a little less and are spending time enjoying life," Swiller said. "We talk about fees, the investments we should've made. We celebrate the passages of our lives together."

Despite talk of grandchildren and the kind of teasing banter often overheard among silver-anniversary couples, Swiller said no one in his group-himself included-is planning to retire. "We love our work and feel this is such an important part of us, we don't ever want to stop doing it."