Acad Psychiatry DOI 10.1007/s40596-014-0083-1
EMPIRICAL REPORT
Helping Psychiatry Residents Cope with Patient Suicide Deepak Prabhakar & Richard Balon & Joan Meyer Anzia & Glen O. Gabbard & James W. Lomax & Belinda ShenYu Bandstra & Jane Eisen & Sara Figueroa & Garton Theresa & Matthew Ruble & Andreea L. Seritan & Sidney Zisook
Received: 22 December 2012 / Accepted: 19 April 2013 # Academic Psychiatry 2014
Abstract Objective Every clinical specialty has its own high risk patient challenges that threaten to undermine their trainees’ professional identity, evolving sense of competence. In psychiatric training, it is patient suicide, an all-too frequently encountered consequence of severe mental illness that may leave the treating resident perplexed, guilt-ridden, and uncertain of their D. Prabhakar (*) Henry Ford Health System, Detroit, MI, USA e-mail: [email protected] R. Balon Wayne State University, Detroit, MI, USA J. M. Anzia Northwestern University Feinberg School of Medicine, Chicago, IL, USA G. O. Gabbard : J. W. Lomax Baylor College of Medicine, Houston, TX, USA B. S. Bandstra Stanford University School of Medicine, Stanford, CA, USA J. Eisen Brown University, Providence, RI, USA S. Figueroa University of Michigan, Ann Arbor, MI, USA G. Theresa Oklahoma University Health Sciences Center, Oklahoma City, OK, USA M. Ruble Cambridge Health Alliance, Cambridge, MA, USA A. L. Seritan UC Davis, Sacramento, CA, USA S. Zisook University of California, San Diego, CA, USA
suitability for the profession. This study evaluates a patient suicide training program aimed at educating residents about patient suicide, common reactions, and steps to attenuate emotional distress while facilitating learning. Methods The intervention was selected aspects of a patient suicide educational program, “Collateral Damages,”—video vignettes, focused discussions, and a patient-based learning exercise. Pre- and post-survey results were compared to assess both knowledge and attitudes resulting from this educational program. Eight psychiatry residency training programs participated in the study, and 167 of a possible 240 trainees (response rate=69.58 %) completed pre- and post-surveys. Results Knowledge of issues related to patient suicide increased after the program. Participants reported increased awareness of the common feelings physicians and trainees often experience after a patient suicide, of recommended “next” steps, available support systems, required documentation, and the role played by risk management. Conclusions This patient suicide educational program increased awareness of issues related to patient suicide and shows promise as a useful and long overdue educational program in residency training. It will be useful to learn whether this program enhances patient care or coping with actual patient suicide. Similar programs might be useful for other specialties. Keywords Patient suicide . Psychiatry residents . Curriculum Regardless of clinical specialty, bad outcomes happen. In psychiatry, the most serious and tragic “bad outcome” of the serious and chronic conditions psychiatrists treat, patient suicide, is also one of the most difficult to accept and cope with in all medicine [1, 2]. Patient suicide has been called an occupational hazard for psychiatrists: an event almost all psychiatrists in practice encounter, often many times. It is difficult to deal with at any period of a psychiatrist’s career, but is especially
Acad Psychiatry
during residency [3-5]. Residents often blame themselves and may be too riddled with self-doubt, shame, and guilt about selfperceived omissions or commissions to seek help. Yet, resident physicians are an especially vulnerable population whose early experiences with patient suicide may shape their future behaviors and coping skills [6]. This situation is compounded by the nature of psychiatric training, which generally emphasizes inpatient rotations, with the most ill and potentially suicidal patients, for the most junior trainees [6]. And, although all training programs emphasize teaching suicide risk assessment and procedures to mitigate risk, few provide training aimed at helping residents cope with the aftermath of patient suicide when all attempts at treatment and prevention fail [4-10]. In a survey of chief residents of psychiatry training programs across the USA, only 19 % of the respondents reported feeling prepared for the aftermath of patient suicide [11]. The aim of this study is to pilot test a new curriculum aimed at helping psychiatry residents learn more about suicide, common reactions to patient suicide, and useful resources and actions as a first step towards helping trainees adaptively cope with this tragic event.
Methods
(ACGME) competencies as a means to stimulate discussion; and (4) pre- and post-questions. Sample Immediately after the Collateral Damages curriculum was presented as a workshop at the 2010 Annual meeting of the American Association of Directors of Psychiatry Presidency Training (AADPRT), participating training directors were asked if they wanted to volunteer their programs to pilot test the curriculum. They were told a DVD and a user’s guide would be provided and that they would have to agree to present the curriculum to residents and obtain pre-session surveys and immediate post-session surveys during the next academic year. Eight residency training programs volunteered. The programs represented different regions of the USA: Midwest (Northwestern University, University of Michigan, Wayne State University), Northeast (Brown University, Cambridge Health Alliance), South (University of Oklahoma), and West (Stanford University, University of California at Davis). The dedicated didactic sessions occurred between November 2010 and October 2011. Respective Institutional Review Boards approved the study for each site. Attendance at the program and completion of the survey instrument implied informed consent.
Development and Contents of Curriculum Teaching Session As previously described [7], a group of senior investigators, along with residents and recent graduates, developed a highly interactive curriculum, called Collateral Damages, aimed at providing psychiatry training programs tools to help trainees learn: (1) suicide is often the result of serious mental illness; (2) even experienced, highly-acclaimed psychiatrists have patients who die by suicide; (3) anger, blame, guilt, shame, relief, and myriad other grief-related reactions are common; and (4) departmental and institutional guidelines focused on dealing with patient suicide may ultimately enhance healthy coping. The Collateral Damages curriculum is contained in a DVD that consists of (1) a video program that includes introductory comments; five brief vignettes from clinicians (two from senior faculty, two from junior faculty, and one from a trainee) on their patients who killed themselves and their immediate emotions, thoughts, and behaviors; a panel discussion of the five psychiatrists who have provided their narratives plus two senior training directors that focuses on universal themes, processes, and procedures to follow after a patient suicide, principles of dealing with families, critical incident review, risk management, and the roles of counseling/ supporting trainees and colleagues; and closing comments; (2) a PowerPoint presentation emphasizing suicide-related basic epidemiological facts, emotional reactions to patient suicide, and a brief overview of resources available to grieving individuals; (3) a patient-based case learning exercise covering Accreditation Council for Graduate Medical Education
Although we presented a structured user’s guide describing the way the curriculum was to be implemented at the coordinating site, Wayne State University, each program was instructed to use the program according to their individual needs and adjust the content as deemed necessary. We allowed this flexibility considering that individual programs may already have some pieces of the educational curriculum in place. The user’s guide suggested the curriculum could be given as a one-time, 90-min workshop, to include the following: 1. Pre-test survey to be distributed and collected during the first few minutes. 2. A 15-min segment from the “Collateral Damages” DVD—opening remarks by Dr. Glen Gabbard and two senior clinician narratives. 3. Open floor discussion for 10 min. 4. A second 15-min segment from “Collateral Damages”—a resident narrative and closing remarks from Dr. Glen Gabbard. 5. Open floor discussion for 10 min 6. A patient-based learning exercise to be discussed for 30 min. This exercise included core issues related to patient suicide such as the importance of collateral information, risk of suicide in patients with schizophrenia, impact of case load, medical knowledge, and risk management procedures.
Acad Psychiatry
7. Open floor discussion for 10 min to answer any queries, highlight key take home points and discuss possible follow-up or next steps. 8. Distribution, completion, and collection of the post-test survey.
Survey Instrument and Implementation In addition to basic demographic information contained in the pre-test survey, the pre- and post-test surveys were composed of items measuring the trainees’ awareness and understanding of issues related to patient suicide such as common “facts,” awareness of common feelings, steps to take after completed patient suicide, support systems, documentation and risk-management, and likelihood of consultation with surviving family members, mentors, supervisors, department chair, and training director. Surveys were completed anonymously. Differences between pre- and post-test surveys were compared using linear trend chi-square for ordinal variables and chi-square for nominal variables. Because the surveys were completed anonymously, it was not possible to match individual pre- and post-test responses; therefore, independent tests were used. Statistical significance was defined as a two-sided p value
EMPIRICAL REPORT
Helping Psychiatry Residents Cope with Patient Suicide Deepak Prabhakar & Richard Balon & Joan Meyer Anzia & Glen O. Gabbard & James W. Lomax & Belinda ShenYu Bandstra & Jane Eisen & Sara Figueroa & Garton Theresa & Matthew Ruble & Andreea L. Seritan & Sidney Zisook
Received: 22 December 2012 / Accepted: 19 April 2013 # Academic Psychiatry 2014
Abstract Objective Every clinical specialty has its own high risk patient challenges that threaten to undermine their trainees’ professional identity, evolving sense of competence. In psychiatric training, it is patient suicide, an all-too frequently encountered consequence of severe mental illness that may leave the treating resident perplexed, guilt-ridden, and uncertain of their D. Prabhakar (*) Henry Ford Health System, Detroit, MI, USA e-mail: [email protected] R. Balon Wayne State University, Detroit, MI, USA J. M. Anzia Northwestern University Feinberg School of Medicine, Chicago, IL, USA G. O. Gabbard : J. W. Lomax Baylor College of Medicine, Houston, TX, USA B. S. Bandstra Stanford University School of Medicine, Stanford, CA, USA J. Eisen Brown University, Providence, RI, USA S. Figueroa University of Michigan, Ann Arbor, MI, USA G. Theresa Oklahoma University Health Sciences Center, Oklahoma City, OK, USA M. Ruble Cambridge Health Alliance, Cambridge, MA, USA A. L. Seritan UC Davis, Sacramento, CA, USA S. Zisook University of California, San Diego, CA, USA
suitability for the profession. This study evaluates a patient suicide training program aimed at educating residents about patient suicide, common reactions, and steps to attenuate emotional distress while facilitating learning. Methods The intervention was selected aspects of a patient suicide educational program, “Collateral Damages,”—video vignettes, focused discussions, and a patient-based learning exercise. Pre- and post-survey results were compared to assess both knowledge and attitudes resulting from this educational program. Eight psychiatry residency training programs participated in the study, and 167 of a possible 240 trainees (response rate=69.58 %) completed pre- and post-surveys. Results Knowledge of issues related to patient suicide increased after the program. Participants reported increased awareness of the common feelings physicians and trainees often experience after a patient suicide, of recommended “next” steps, available support systems, required documentation, and the role played by risk management. Conclusions This patient suicide educational program increased awareness of issues related to patient suicide and shows promise as a useful and long overdue educational program in residency training. It will be useful to learn whether this program enhances patient care or coping with actual patient suicide. Similar programs might be useful for other specialties. Keywords Patient suicide . Psychiatry residents . Curriculum Regardless of clinical specialty, bad outcomes happen. In psychiatry, the most serious and tragic “bad outcome” of the serious and chronic conditions psychiatrists treat, patient suicide, is also one of the most difficult to accept and cope with in all medicine [1, 2]. Patient suicide has been called an occupational hazard for psychiatrists: an event almost all psychiatrists in practice encounter, often many times. It is difficult to deal with at any period of a psychiatrist’s career, but is especially
Acad Psychiatry
during residency [3-5]. Residents often blame themselves and may be too riddled with self-doubt, shame, and guilt about selfperceived omissions or commissions to seek help. Yet, resident physicians are an especially vulnerable population whose early experiences with patient suicide may shape their future behaviors and coping skills [6]. This situation is compounded by the nature of psychiatric training, which generally emphasizes inpatient rotations, with the most ill and potentially suicidal patients, for the most junior trainees [6]. And, although all training programs emphasize teaching suicide risk assessment and procedures to mitigate risk, few provide training aimed at helping residents cope with the aftermath of patient suicide when all attempts at treatment and prevention fail [4-10]. In a survey of chief residents of psychiatry training programs across the USA, only 19 % of the respondents reported feeling prepared for the aftermath of patient suicide [11]. The aim of this study is to pilot test a new curriculum aimed at helping psychiatry residents learn more about suicide, common reactions to patient suicide, and useful resources and actions as a first step towards helping trainees adaptively cope with this tragic event.
Methods
(ACGME) competencies as a means to stimulate discussion; and (4) pre- and post-questions. Sample Immediately after the Collateral Damages curriculum was presented as a workshop at the 2010 Annual meeting of the American Association of Directors of Psychiatry Presidency Training (AADPRT), participating training directors were asked if they wanted to volunteer their programs to pilot test the curriculum. They were told a DVD and a user’s guide would be provided and that they would have to agree to present the curriculum to residents and obtain pre-session surveys and immediate post-session surveys during the next academic year. Eight residency training programs volunteered. The programs represented different regions of the USA: Midwest (Northwestern University, University of Michigan, Wayne State University), Northeast (Brown University, Cambridge Health Alliance), South (University of Oklahoma), and West (Stanford University, University of California at Davis). The dedicated didactic sessions occurred between November 2010 and October 2011. Respective Institutional Review Boards approved the study for each site. Attendance at the program and completion of the survey instrument implied informed consent.
Development and Contents of Curriculum Teaching Session As previously described [7], a group of senior investigators, along with residents and recent graduates, developed a highly interactive curriculum, called Collateral Damages, aimed at providing psychiatry training programs tools to help trainees learn: (1) suicide is often the result of serious mental illness; (2) even experienced, highly-acclaimed psychiatrists have patients who die by suicide; (3) anger, blame, guilt, shame, relief, and myriad other grief-related reactions are common; and (4) departmental and institutional guidelines focused on dealing with patient suicide may ultimately enhance healthy coping. The Collateral Damages curriculum is contained in a DVD that consists of (1) a video program that includes introductory comments; five brief vignettes from clinicians (two from senior faculty, two from junior faculty, and one from a trainee) on their patients who killed themselves and their immediate emotions, thoughts, and behaviors; a panel discussion of the five psychiatrists who have provided their narratives plus two senior training directors that focuses on universal themes, processes, and procedures to follow after a patient suicide, principles of dealing with families, critical incident review, risk management, and the roles of counseling/ supporting trainees and colleagues; and closing comments; (2) a PowerPoint presentation emphasizing suicide-related basic epidemiological facts, emotional reactions to patient suicide, and a brief overview of resources available to grieving individuals; (3) a patient-based case learning exercise covering Accreditation Council for Graduate Medical Education
Although we presented a structured user’s guide describing the way the curriculum was to be implemented at the coordinating site, Wayne State University, each program was instructed to use the program according to their individual needs and adjust the content as deemed necessary. We allowed this flexibility considering that individual programs may already have some pieces of the educational curriculum in place. The user’s guide suggested the curriculum could be given as a one-time, 90-min workshop, to include the following: 1. Pre-test survey to be distributed and collected during the first few minutes. 2. A 15-min segment from the “Collateral Damages” DVD—opening remarks by Dr. Glen Gabbard and two senior clinician narratives. 3. Open floor discussion for 10 min. 4. A second 15-min segment from “Collateral Damages”—a resident narrative and closing remarks from Dr. Glen Gabbard. 5. Open floor discussion for 10 min 6. A patient-based learning exercise to be discussed for 30 min. This exercise included core issues related to patient suicide such as the importance of collateral information, risk of suicide in patients with schizophrenia, impact of case load, medical knowledge, and risk management procedures.
Acad Psychiatry
7. Open floor discussion for 10 min to answer any queries, highlight key take home points and discuss possible follow-up or next steps. 8. Distribution, completion, and collection of the post-test survey.
Survey Instrument and Implementation In addition to basic demographic information contained in the pre-test survey, the pre- and post-test surveys were composed of items measuring the trainees’ awareness and understanding of issues related to patient suicide such as common “facts,” awareness of common feelings, steps to take after completed patient suicide, support systems, documentation and risk-management, and likelihood of consultation with surviving family members, mentors, supervisors, department chair, and training director. Surveys were completed anonymously. Differences between pre- and post-test surveys were compared using linear trend chi-square for ordinal variables and chi-square for nominal variables. Because the surveys were completed anonymously, it was not possible to match individual pre- and post-test responses; therefore, independent tests were used. Statistical significance was defined as a two-sided p value
