The article entitled “Encountering Patient Suicide: A Resident’s Experience” (1) is an interesting description of the personal toll that the suicide of a patient may take on an early career resident. The authors review the limited data on the curriculum of residency training programs that specifically address educational programs designed to help residents after a patient suicide. The authors recommend additional formal supports within psychiatry training programs. We wholeheartedly concur with these recommendations and feel they are long overdue.
We would add that similar supports should be implemented in medicine and surgery residency programs. Residents in these programs also encounter the unexpected death of a patient but have limited resources available to assist them in processing this loss. Many of the recommendations made in this article should be used to design effective programs for medical and surgical residents. Psychiatry and psychology training programs can, and should, take the lead in developing these programs.
The authors report that the experience of a patient suicide is not uncommon (a wide range of incidence of patient suicide during residency [14% to 68%]). Similarly, medical and surgical residents involved in direct patient care are likely to encounter the unexpected death of a patient. Over 40% of all deaths take place in a hospital, a setting where residents and interns are intimately involved with caring for dying patients and interacting with their families (2). Medical education rarely provides adequate training for students and physicians to effectively manage this emotionally charged issue (3).
Deaths from medical illnesses, like suicide, are often difficult to prevent, even in the care of the most experienced clinician. Yet the prevailing medical culture continues to view death as a medical failure (4), and physicians early in their careers are particularly vulnerable to second-guessing their medical decisions. As a result, they often experience an overwhelming sense of failure after a patient’s death, and feel alone with their pain and distress. Whether spoken or implied, the sense that “if only” the physician had done or not done something the patient would be alive is often in the air (5). Both a completed suicide and an unanticipated death on a medical or surgical unit can therefore directly affect a physician’s professional development. In both cases, early career physicians may doubt their professional competence. Physicians may view the professional stigmata of the death of their patient as failure or evidence that they mismanaged the case (6).
After the death of a patient, medical and surgical residents often question how to discuss the death with the family survivors who may be depressed, anxious, or angry (5). Although there are model programs to address breaking “bad news” to patient families (7), few programs provide this type of training and work constraints may limit the time that residents can spend with the families. In addition, residents may worry about legal action and have concerns about the possibility of negative evaluations, suspension or termination from clinical sites or training programs, and interruption in completing their residency (8).
The educational needs of a psychiatry resident who experiences a patient suicide are therefore similar to the needs of a medical or surgical resident who experiences an unexpected patient death. We agree with the call for specific programs to assist residents in preparing for and managing themselves emotionally, practically, and legally after a suicide. We would add that graduate medical education should require that all residency programs provide a curriculum of support for residents in processing the death of their patients, particularly when the death is unexpected. For many residents, this can be the seminal event in their careers and provide a model for how they will cope with other highly emotionally charged experiences as a physician.
Psychiatry and psychology residency directors should take the lead and institute comprehensive programs that will serve as models for other departments in the medical school. These programs will serve to help residents understand and address their personal feelings related to patient suicide, but could easily be extended to aid residents, medical students, and faculty throughout the medical school.