Commentary
Improving Support of Residents After a Patient Suicide: A Residency Case Study Christina Mangurian, M.D., Elizabeth Harre, M.D. Aaron Reliford, M.D., Andrew Booty, M.D. Francine Cournos, M.D.
T
he suicide of a patient is arguably the most traumatic event that can occur during a psychiatrist’s professional life. A substantial portion of psychiatrists in general practice (15%– 68%) will experience at least one patient suicide during their careers (1, 2), and approximately onethird of psychiatric residents experience a patient suicide during residency (3). A patient’s suicide frequently leads the treating psychiatrist to experience considerable stress, guilt, shame, anxiety, and even PTSD-like symptoms of intrusion, hypervigilance, depersonalization, and avoidance (4). Residents, at the early stage of their careers, are uniquely vulnerable to stress from this event (5). A patient suicide may cause the resident to doubt his or her clinical skills, the decision to enter psychiatry, and previous treatment decisions (5). Residents may also feel anger toward their supervisors for providing inadequate guidance, and co-residents may feel relief that they were not the treating resident (6). However, in their positions as trainees, residents have a unique opportunity for personal and professional growth at the time of such an event (7, 8). Nonetheless, in one study of Canadian medical students and residents (9), of whom nearly two-thirds had encountered at least one suicide, only one-third had received any formal education regarding the impact of suicide on residents. It is ironic that we as psychiatrists, particularly attuned to the needs of others, often avoid discussing these issues
Received October 16, 2008; revised February 1, 2009; accepted February 27, 2009. Drs. Mangurian, Harre, Reliford, and Cournos are affiliated with the Department of Psychiatry at Columbia University in New York City; Dr. Booty is affiliated with the Department of Psychiatry at the University of California, San Francisco. Address correspondence to Christina Mangurian, M.D., 1051 Riverside Dr., Box 100, New York, NY 10032;
[email protected] (e-mail). Copyright © 2009 Academic Psychiatry
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with colleagues, especially given the potential distress such events may cause. We each experienced the suicide of one patient during our residencies at Columbia and discovered several deficiencies in our methods for dealing with them. The composite patient described in Appendix 1 illustrates some of these problems. First, we found a lack of basic knowledge by residents in several areas, including the expected emotional responses, the frequency of patient suicides during residency, and helpful institutional procedures that a resident could access. Second, we noted isolation and lack of emotional support and appropriate mentorship for the affected resident. Finally, there was a lack of institutional support and constructive, noncritical reviews of suicide. To address these problems at our institution and the call by Academic Psychiatry for developing supportive and educational interventions for residents experiencing patient suicide (10), we describe here the interventions we developed at Columbia University, including curricular changes, development of a crisis support team, and a formal review of the event, and other constructive and reparative measures we have taken. Interventions Curricular Developments Gitlin (8) recommends that courses be provided to residents early in training, before they experience a patient suicide, and that they be exposed to modeling by senior residents and/or seasoned faculty who have had the experience of patient suicide themselves. We have done this at our institution and now have an experienced faculty member conduct an anticipatory seminar class in which postgraduate year one (PGY-1) residents learn statistics about Academic Psychiatry, 33:4, July-August 2009
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how common patient suicide is during residency, typical responses of residents after patient suicides, and useful coping strategies. This seminar also provides an important forum for residents to voice their fears about such an event. Then, during the PGY-2 orientation, we outline resources available to residents after a patient suicide. This information has been compiled into a “Resource Guide for Residents After a Patient Suicide” that is available on our residency website as well as the APA website (11). This packet includes typical responses to patient suicide, suggestions for ways to cope, suggested questions for supervisors during this process, logistical practices of each clinic or inpatient unit, listing of risk management organizations and terms that residents might encounter, answers to common legal questions, and references from the literature to help a resident after the event. This resource also lists peer and faculty who are available to residents and specifies which of them have personally experienced patient suicide. This specification was included to minimize isolation and model that a successful future is possible after this event (8). Crisis Support Team To address the initial isolation and lack of emotional support and mentorship in these situations, we developed a formalized institutional response to facilitate a resident’s personal and professional development and enhance learning, growth, and functioning after a patient suicide. Emulating similar models at institutions including Baylor and Stanford, we formed a crisis support team to be activated immediately upon discovery of the suicide of a patient currently or recently within the care of a resident. The team consists of resident “buddies” and faculty mentors who themselves have either lost patients to suicide or undergone training in this area and who coordinate with one another to provide emotional support to affected residents. The team may also collaborate with the House Staff Crisis Service, so that, when appropriate, formal counseling can also be provided, free of cost. The crisis support team at Columbia is activated when, in response to a suicide of a resident’s patient, the chief resident contacts the head of the team, who selects a resident buddy and faculty mentor to assist the affected resident. The buddy and mentor will, in a coordinated fashion, arrange to meet with the resident to determine how they may best provide nonintrusive emotional support. We replicated key features of the Baylor program, including helping residents in concrete ways, such as explaining unit procedures after a suicide, offering time Academic Psychiatry, 33:4, July-August 2009
away from work, and accompanying the resident to related meetings (e.g., risk management). Mentors will continue to contact the resident for a period of time after the suicide. The frequency and duration of these meetings is determined by the resident and mentor and tailored to the needs of the resident. We are also considering expanding the purview of the team to include situations in which trainees are assaulted by patients, stalked, or named in malpractice suits or other potentially traumatic events. Since its inception approximately 2 years ago, the crisis support team has been invoked three times, once for a suicide and twice for suicide attempts. In each case, residents reported feeling supported. We have found that residents elicit this support under various circumstances. For example, one resident may have treated the patient weekly for several months, whereas another resident may have evaluated the patient only once in the remote past. We view this as an important aspect of this crisis support team, as it tailors support during this difficult experience to fit the specific resident’s needs and personal experience. At our institution, we know of two suicide attempts that were not brought to the attention of the crisis support team. Eliciting this kind of support after a patient suicide is an individual decision. Some residents prefer not to use a service like the crisis support team and to rely on their own resources. Nevertheless, we cannot anticipate who will find this helpful or not; which highlights the importance of offering this service to all affected residents as opposed to requiring participation. We believe it is instrumental that all residents are aware of the existence of this crisis support team, so we have been making presentations at orientations, anticipatory suicide classes, related presentations, and resident lunches. We are also tracking the utilization of the crisis support team for future evaluation.
Morbidity and Mortality (“M&M”) Meetings To address lack of institutional support, we have created a formal, noncritical review process. We believe there is a need for such standardized “postvention” measures after a suicide to minimize the psychological impact on residents. Critical reviews and “psychological autopsies” in psychiatry have been shown to facilitate examination of the events and have a valuable focus on education and modeling. However, as implemented thus far, such meetings have not addressed the unique emotional impact of patient suicide on a psychiatric resident and have emphasized medico-legal issues and blame at the expense of providing support (3, 12). As noted by Fang et al. (13), if resident http://ap.psychiatryonline.org
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support is underemphasized, adverse psychological impact is more likely. Interestingly, there is only one published report of a traditional psychiatry morbidity and mortality conference at an academic medical center (14). Emphasis was on formal structure, regular meetings, monitoring clinical outcomes, and quality assurance. Although the authors mentioned several of the problems we have encountered, specifically resident concerns about patient confidentiality, litigation, and feeling emotionally overwhelmed and demoralized, there was no discussion of how these important concerns were addressed or how much focus they received in these meetings. At Columbia, we are starting to implement regular reviews of adverse events (suicide and other violence), focusing on quality assurance, education, and structure. However, we are also striving to address the emotional impact on the treating resident in an environment with resident-selected, supportive clinicians who are open about their own experiences with patient suicide. Ideally, these regular reviews could also provide support to all staff who are affected by patient suicide, including attending supervisors, nursing staff, social workers, occupational therapists, and therapy aides. Unfortunately, in carrying out these meetings, the first problem we encountered was confidentiality. Given that an academic psychiatry department is a small community and that suicide is a rare but highly visible event, even presentation of minimum material could allow for inadvertent identification of a patient. Another major concern was potential vulnerability to litigation. Although the law varies from state to state, we have been hampered by the lack of privilege of those in attendance at our meetings because there is an official incident review committee that reviews adverse hospital events. These meetings were put on hold until the litigation issue could be resolved. We learned that sufficient privilege and protection from litigation can be obtained by subsuming these meetings under the rubric and jurisdiction of the quality assurance departments at each hospital. We have named the body conducting these meetings the crisis support committee, which oversees all activities of the crisis support team. Both the committee and team are led by the same senior resident who has experienced a patient suicide. All activities of the crisis support committee and activities of the crisis support team will be regularly monitored by the quality assurance department. In our facility, sufficient privilege is maintained only if all attendants are designated as medical staff. It is our recommendation that any program considering instituting a similar committee should 280
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consult extensively with its quality assurance department to ensure adequate compliance with specific institutional and state regulations. We hope that the crisis support committee will institute regular, monthly meetings focusing equally on education, prevention, and quality assurance and on the provision of the necessary suicide “postvention” supportive elements that would lessen the emotional impact of a patient’s suicide on a resident and provide formalized institutional support through a noncritical review process.
Workshops and Publications Gitlin (8) recommends reparative and constructive behaviors as a means of coping after a patient suicide. We believe these are most useful after the resident has had some distance from the suicide itself. At Columbia, we followed this recommendation to the fullest by putting our energy into implementing the programs mentioned earlier. We also presented “Impact of Patient Suicide on Psychiatry Residents: A Workshop Discussion” at the 2007 APA meeting, and five residents and two faculty members shared their stories. More than 50 participants came to hear about our experiences and share their own. This workshop minimized the isolation of attendees and gave them a place to share with others who have gone through the same experience. At the end of the workshop, attendees had the following suggestions: reduce clinical responsibilities of residents after the event, consider a crisis support team, provide direct supervision during risk management interviews, and reconsider whether the primary attending should be the main supervisor and source of support for residents in this situation. We used many of these recommendations to create the crisis support team as described earlier. We hope to hold this workshop yearly in an effort to minimize isolation within the larger psychiatric community. Finally, writing this article helped each of us heal and grow a little more from this difficult experience. We hope that it will be helpful to others as well and that the experience of patient suicide can be used to improve patient care and better support other residents who face this difficult experience. We also hope to encourage other institutions to enhance the support they provide to residents who experience the suicide of a patient. By responding to the trauma that a resident experiences when a patient commits or attempts suicide, programs will not only be offering support, but they will also be modeling less stigmatizing attitudes toward the psychological vulnerabilities Academic Psychiatry, 33:4, July-August 2009
MANGURIAN ET AL. APPENDIX 1. Composite Case of a Patient Suicide Mr. Brown, 56 years old, was admitted to the general inpatient psychiatry unit of a major urban teaching hospital with a recurrence of major depression with psychotic features. He was treated by Dr. Smith, a second-year resident on her first psychiatry rotation, under the supervision of an attending psychiatrist. During the course of his 3-week hospitalization, Mr. Brown improved significantly with electroconvulsive therapy, pharmacotherapy, and supportive psychotherapy and was discharged to the care of his outpatient psychiatrist on the last day of Dr. Smith’s rotation. A week later, on a different rotation, Dr. Smith received a page from her former attending. His voice sounded distant. “I thought you would want to know . . . we got a call a few days ago. Mr. Brown jumped off of the roof of his apartment building early Monday. He’s dead.” The attending told her that he would be in touch about a “Q and A.” Dr. Smith’s hands were shaking, and her mind was blank. “This is what it feels like to be in shock,” she thought. She left a message for her boyfriend and went to the bathroom to compose herself. Afraid of how she would be viewed by other residents and the department, she told no one what had happened. Later that day, the unit chief from her old rotation called Dr. Smith to “touch base.” “Do not blame yourself,” he told her. He referred to staff meetings addressing the suicide that had already occurred since Dr. Smith had rotated off the unit. Later, her residency director paged Dr. Smith to ask, “Why didn’t you tell us about the patient suicide sooner?” Dr. Smith did not sleep well that night. She lay awake, sad, disbelieving, and horrified. She felt guilty, as if she had failed Mr. Brown and his family. She dreaded facing her fellow residents, supervisors, and residency director. She also felt an uncomfortable anger at Mr. Brown, who had destroyed her treatment and hard work and put her in this situation. She questioned herself: Did she have bad judgment? Had there been warnings that a “better” doctor would have noticed? Was she in the wrong field? Did she want to be in a field in which she could work her hardest and still have such an outcome? She wondered what she should do. Should she call Mr. Brown’s family? Should she apologize? Should she have gone to his funeral? She worried about being sued. That night, and for several days after, she could not stop picturing Mr. Brown in the plaid shirt he had worn on the day of discharge. About a month after hearing the news, Dr. Smith attended a case review on the unit by hospital administrators. She was quiet as the attending and head nurse answered questions. She felt sick to her stomach. She thought about calling the therapist she had seen in medical school, but her new rotation was busy, and leaving the unit was difficult. Her boyfriend and parents were supportive but had no experiences from their own lives to allow them to be helpful. Dr. Smith felt alone. Dr. Smith continued on to her third year of residency, treating predominantly outpatients. She continued to feel anxious when treating suicidal patients, although less so with time. However, each anniversary of her patient’s death continues to give her pause.
that we study and treat in others but have so much difficulty in acknowledging among ourselves. At the time of submission, the authors disclosed no competing interests.
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