Supporting Residents in the Wake of Patient Suicide

Case Vignette

A patient arrived on the psychiatric unit after being transferred from the medicine service, where he had been treated in the intensive care unit following a suicide attempt by polypharmacy ingestion. “Mr. M” gave few details about his life and was never consistent with the team about why he tried to commit suicide. The treatment team worked with him and his family for a week, during which time he was diagnosed with depression, cognitive-behavioral therapy was initiated, and a new medication for depression was started. Multiple safety evaluations were performed during the patient's hospitalization and prior to discharge, but Mr. M consistently denied thoughts or urges to kill himself. His family visited regularly and looked forward to having him come home. After a thorough safety plan was created and reviewed with his family, he was discharged to his family's care on a Friday afternoon. Later that day, he committed suicide at home. A debrief session was scheduled with staff at the hospital but did not occur until the resident had rotated off service onto a month of night float.

Those who practice medicine are often faced with the inevitability of death, often at untimely or tragic times. Psychiatry is no exception, and patient suicide is an unfortunately common cause of death (1). A review of the literature (2) found that between 31% and 69% of psychiatry residents experience patient suicide as a trainee. Experiencing a patient committing suicide during residency may induce symptoms of acute stress disorder, posttraumatic stress disorder (1), shame, guilt, self-doubt, and professional dissatisfaction (3–5). Even though patient suicide is a known aspect of psychiatry, its impact on trainees is palpable and at times severe.

The experience of suicide can be particularly difficult for new trainees. It can leave residents feeling isolated and questioning their abilities. Fear of being seen as weak or incompetent may cause residents to isolate and internalize the loss, leading them to feel that they are the only ones who have lost a patient. Although there is no direct connection between experiencing a patient suicide and developing burnout, physicians experience a high rate of provider fatigue during their careers, as evidenced by up to 60% of physicians reporting symptoms of burnout and professional distress (6–9). Symptoms of burnout and provider fatigue result in poor patient care, patient dissatisfaction, more frequent medical errors, and more frequent malpractice lawsuits (8–10).

Patient Suicide at the University of Colorado

Over the past academic year, there were at least four patient suicides experienced by residents at the University of Colorado's Psychiatry Resident Program. Given the documented impact such events can have on trainees (1–5), it became clear that residents need to learn about all of the resources available to them when dealing with patient suicide during intern orientation. Furthermore, there is literature supporting the creation of curricula teaching residents about patient suicide (11).

We constructed a new curriculum about patient suicide designed to help incoming intern residents feel more supported, less isolated, and better informed about how our institution supports residents when one of their patients attempts or completes suicide. We then assessed the influence of this revised curriculum on the attitudes of new intern psychiatry residents.

Method

Curriculum Details

To better prepare incoming residents, the topic of patient suicide is now addressed during intern orientation. Through collaboration between residents who have experienced patient suicide and the director of student mental health, a 4-hour course was developed to address both safety assessment and patient suicide. The course discusses safety assessments, a packet of resident resources, and the study institution's response to patient suicide. This course also includes two written cases and a role-playing exercise, which are each followed by a group discussion. At the end of the course, a panel of psychiatrists with different levels of experience discusses their experiences with patient suicide. The panel includes two residents, two psychiatrists in practice, and one retired psychiatrist. Incoming interns are then given the opportunity to ask questions for the remainder of the session.

Measuring the Effectiveness of the Intern Orientation Initiative

The effectiveness of the orientation session was evaluated with pre- and post-session surveys completed by all 12 incoming interns. The survey included 11 items graded on a Likert scale, as well as a question to ascertain whether the intern had previously experienced a patient suicide. Within this scale, a score of 1 corresponded with strongly disagree, 2 with disagree, 3 with neutral, 4 with agree, and 5 with strongly agree. Feedback on the quality of the session was also obtained with an additional post-session survey. Data from the surveys were compiled, and question scores from Likert scales were averaged for pre- and post-session surveys to determine possible changes to future sessions. Compiled scores for each question were also compared using an unmatched, one-tailed t-test to determine significance of change.

Results

Following the orientation session, there was no significant change in interns' confidence in their ability to complete a thorough safety assessment (p=0.08) (Table 1). Significant improvement occurred in awareness of resources available to residents (p<0.001), the process of accessing these resources in times of stress (p<0.001), and awareness of the program's process for supporting residents who experience patient suicide (p<0.001). Furthermore, incoming interns had a significant increase in their confidence that they could handle a patient suicide event (p=0.04), support a peer through a patient suicide (p=0.01), or provide referrals to peers in need of additional support after experiencing the suicide of a patient (p<0.001). There was no significant change in participants' interest in pursuing their own mental health care, their rated ability to discuss patient suicide with a peer, or their feelings about previous education regarding physician support. No new intern reported having experienced patient suicide.

Discussion

The possibility of patient suicide is ever present for psychiatrists and can become a troubling reality even early in the intern year, before newly anointed MDs have had a chance to develop their identity as physicians. For this reason, it is vitally important to make sure 1) incoming residents are capable and prepared to perform appropriate safety assessments and 2) that they are aware of the support system available to them should they experience a patient suicide. As a result of the experiences of members of the 2015 intern class at the study institution, it became clear that more could be done to prepare new residents for how to deal with a patient suicide, in addition to refining and strengthening the available support system.

Limitations

The limitations of this analysis include its small sample size, inclusion of results from a single year, and lack of survey results from prior-year residents. Additionally, these results are only applicable to the University of Colorado interns and may not be applicable to other programs. Finally, given the importance of this curriculum, it would not be ethical to randomize participation between the current and prior curriculum for the purposes of comparison. Instead, continued assessment and analysis of participant responses over multiple years will be required in order to understand the impact this curriculum may have on residents following patient suicide experienced during residency.

Future Directions

The continued goal of this and similar projects is to improve the mental health of psychiatry residents at all institutions during all years of training. To that end, we will continue to address the issue of education and support surrounding patient suicide in the coming years. First, we plan to continue with the interventions above, making improvements based on resident and faculty feedback as appropriate. For example, we will attempt to improve education regarding safety assessment to improve interns' confidence that this is something they can do upon starting their rotations. When residents do experience patient suicide, they will have the voluntary opportunity to discuss how this loss affected them, whether they felt supported, whether the program followed their own policies, and how we can improve didactics about patient suicide during training. Using feedback from affected residents, as well as the annual survey results during intern orientation, we will be able to make adjustments to the entire curriculum to improve the ways our program supports residents in the wake of patient suicide. Furthermore, we will collaborate with each clinical site to determine whether there are site-specific protocols in place that should be added to the patient suicide checklist or site-specific orientations.

Key Points/Clinical Pearls