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Medical Students’ Responses to an Inpatient Suicide: Opportunities for Education and Support

Received September 20, 2006; revised January 20, 2007; accepted March 22, 2007. From the Uniformed Services University of the Health Sciences, Bethesda, Maryland. Address correspondence to Dr. Hamaoka, USUHS, Department of Psychiatry, 4301 Jones Bridge Road, Bethesda, MD 20814; dhamaoka{at}usuhs.mil (e-mail).

ABSTRACT

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OBJECTIVE: The authors review third-year medical students’ questionnaires to identify the perceptions, themes, and recommendations following an inpatient suicide. METHOD: The authors reviewed the needs assessment information collected 1 year after an inpatient suicide. The information, originally gathered through responses to a voluntary e-mail questionnaire, was reviewed for general themes, types of responses, and general recommendations. RESULTS: Nearly all students were sensitive to affected colleagues. Responses suggested general appreciation of offered support. They also related themes of prevention, personal education, being personally affected, identification, sense of loss, anger, and lack of support. Those involved in the code and on the inpatient service were more likely to feel personally affected. Anger and lack of support were derived exclusively from students on the inpatient service. CONCLUSIONS: Results provide observations and preliminary suggestions regarding medical students’ responses to patient suicides. Understanding these responses can assist medical student educators in responding to such events.

INTRODUCTION

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Few experiences can match the emotional and cognitive challenge of a patient suicide. Denial, disbelief, guilt, sense of failure, and loss of confidence are commonly experienced by clinicians dealing with patient suicide (1, 2). These feelings can be amplified when the suicide occurs in an inpatient setting, where one of the primary tasks for treatment is protecting patients from self-harm.

Medical students are often the most clinically inexperienced and transient members of treatment teams, yet the effects of a patient suicide on medical students have been rarely studied. We examine medical students’ responses to an inpatient suicide as part of a clerkship evaluation and needs assessment process. We offer observations and suggestions on how the education staff can meet the educational and support needs of medical students after such an event.

Precipitating Event

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In the middle of the academic year, during the medical students’ third week (of a 6-week rotation), a mid-40s married, Hispanic male psychiatric inpatient committed suicide by hanging. The suicide occurred on the evening shift, and the psychiatry on-call team (which included one third-year medical student who was rotating on the clerkship) and the surgical code team (which included a third-year medical student not rotating on psychiatry at the time) responded to the code. The inpatient students and house staff were informed of the patient’s death at morning report. No formal announcement of the event was made to the other students on the clerkship.

Method

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In an effort to gain appreciation of the students’ responses and inform department policy regarding such events, we e-mailed a voluntary 11-item questionnaire 13 months after the event. The distribution included 16 students (15 rotating psychiatry students and one surgery student).

Students were asked to describe how they learned of the suicide and their specific role, if any, during the event or in the patient’s care. They were also asked to describe their personal reactions, the most difficult aspect of the event, positive responses (if any) to the event, and to recollect actions taken by the clinical staff to address their concerns. Other items included perceived effect on colleagues, perceived future effect on self, helpful interventions, and ways in which clinical staff might better address medical students’ concerns regarding patient suicides.

All students who received the questionnaire responded (N=16). Two research psychologists and a staff psychiatrist reviewed the responses independently and identified general themes in an iterative fashion. Responses were grouped according to themes via consensus. Reviewers also noted content as it related to the students’ specific role in the suicide response and in the patient’s care.

Results

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Four of the 16 respondents (25%) acknowledged the questionnaire, stated they had nothing to contribute, and returned the questionnaire unanswered. The remaining 12 respondents provided the basis for identified themes (Table 1).

View this table: [in this window] [in a new window]

APPENDIX 1. Medical Students’ Responses to an Inpatient Suicide, Sorted by Theme

"Sensitivity toward colleagues" was represented by nearly all of the students (11/12, 92%). Responses that appropriated to this category included noticing or conveying concern towards a colleague’s response to the event:

"I think we were all shocked and mood was very subdued for the next week. Some of my colleagues coped with the event by intellectualizing it, which appeared very cold and distant."

"Appreciation of help" was also a prominent theme (7/12, 58%). Students varied in the amount of assistance (if any) they required and expressed approval of what was offered:

"I personally felt that the offers of support were sincere offers. I would have felt comfortable approaching a member of the staff."

Several students expressed themes related to "prevention" (7/12, 58%). Questioning the preventability of suicide and recommendations on how to keep patients safe were included in this theme:

"Tighter precautions for patient safety were the most helpful things I learned."

Students expressed themes related to their "personal education" (7/12, 58%). They discussed how they might use this experience to deal with death or what the experience meant to them in a personal context:

"I learned how to deal with the loss of a patient. It brought me closer to some of the people in my life."

"Being personally affected" was conveyed by five of the students (42%). All of these responses were derived from both on-call students and students rotating on the inpatient ward. The responses ranged from feeling saddened or bothered to overt recollections of the event:

"It was disturbing—I had nightmares about it."

An additional theme expressed was "sense of loss" (5/12, 42%), specifically related to the patient and his family. Other themes not highly represented but noteworthy were "identification with the patient" (1/12, 8%), "lack of support" (2/12, 17%), and "anger" (2/12, 17%). Anger and lack of support were derived exclusively from the subset of inpatient psychiatry medical students.

Discussion

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Medical students are expected to learn and actively participate in an environment where they are present for a short time. It is a challenge for educators to meet the educational, emotional, and developmental needs of students when unexpected events occur. Medical students’ well being following such events usually depends on supervisors being cognizant of the students’ potential reactions and the ability to meet these needs.

Denial, questioning clinical competence, isolation, and difficulty in effective grieving were findings from one of the only studies on medical students’ reactions to patient suicide (3). In a wider context, medical students’ responses to patient deaths have been studied (4); these indicated that deaths, particularly sudden deaths, evoke strong emotions; that death and emotions are viewed as negative aspects of medicine; and that support and education in these events are limited. Students have expressed wanting to learn more in dealing with this subject (4, 5) and medical schools have instituted dedicated courses dealing with end-of-life issues (6–8).

Our responses provide several observations for medical student educators as they prepare to respond to a patient suicide. It was reassuring that nearly all students were sensitive to colleagues who appeared affected by the event. Peer support is important and should be encouraged by educators and hospital staff. Fellow students may indeed be the most readily available and acceptable means of support (4). Educational staff should seek medical students’ assessment of student adjustment to quantify how well their needs are being met. Of course, staff must remain cognizant of the fact that students who do not appear outwardly affected may also require support.

Nearly all students closest to the event (i.e., those students on the call team, resuscitation team, inpatient students where the suicide took place) disclosed themes of being personally affected. In addition, those students who presented anger and lack of support themes were exclusively derived from those involved in the patient’s daily clinical care. These findings may indicate that greater exposure to the event may lead to powerful emotional experiences. These findings may also suggest that students who continue to rotate on the unit and are presumably exposed to the aftermath (e.g., investigation, changed procedures, stress of staff and residents) experience the event differently from their colleagues and can potentially be more affected. These subsets may be at greater risk for persistent emotional responses, and their reactions and emotional state should be assessed over time. Support and monitoring should be achieved in a voluntary, sensitive manner with the understanding that one intervention may not suit everyone involved. Supervisors should also be aware that medical students may experience patients’ deaths as emotionally powerful events even when they were not close to the patient (4), as suggested by the off-site student who identified with the patient.

Predictably, students experienced a sense of loss, appreciated the show of assistance, discussed the preventability of suicide, and identified with the patient. Students also discussed how they might use this event in their daily lives and role as a physician. This suggests an opportunity for educators to discuss loss and the accompanying cognitive and emotional responses. Medical schools have implemented formal curricula focusing on death and dying (6–8). Educating and modeling adaptive responses to such unexpected events present a unique opportunity to supplement such instruction. Such real time education can be used when other unexpected events, such as physical restraints and assaults by violent patients, occur.

Primary limitations of this study include the small sample size and distribution of the questionnaire a year after the event. Further systematic studies should address acute as well as longer-term needs of students exposed to suicides and other unexpected events.

Conclusions

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Medical students are expected to learn and manage illness and disease processes in order to promote the well-being of their patients. Rare and unpredictable events, such as suicide, challenge the learning process. Medical educators can help students by being sensitive to likely reactions, providing appropriate support, and utilizing these events to complement education after they occur.

REFERENCES

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1. Litman RE: When patients commit suicide. Am J Psychother 1965; 19:570–576[Medline]
2. Hendin H, Lipschitz A, Maltsberger JT, et al: Therapists’ reactions to patient sucicides. Am J Psychiatry 2000; 157:2022–2027[Abstract/Free Full Text]
3. Krueger DW: Patient suicide: model for medical student teaching and mourning. Gen Hosp Psychiatry 1979; 4:229–233
4. Rhodes-Kropf J, Carmody SS, Seltzer D, et al: "This is just too awful; I just can’t believe I experienced that": medical students’ reactions to their "most memorable" patient death. Acad Med 2005; 80:634–640[CrossRef][Medline]
5. Wear D: "Face-to-face with It": medical students’ narratives about their end-of-life education. Acad Med 2002; 77:271–277[Medline]
6. Ratanawongsa N, Teherani A, Hauer KE: Third-year medical students’ experiences with dying patients during the internal medicine clerkship: a qualitative study of the informal curriculum. Acad Med 2005; 80:641–647[CrossRef][Medline]
7. Binienda J, Schwartz K, Gaspar D: Training in end-of-life care through interaction with dying patients. Acad Med 2001; 76:517[CrossRef][Medline]
8. Fins JJ, Gentilesco BJ, Carver A, et al: Reflective practice and palliative care education: a clerkship responds to the informal and hidden curricula. Acad Med 2003; 78:307–312[Medline]

This article has been cited by other articles:

				J. H. Coverdale, L. W. Roberts, and A. K. Louie Encountering Patient Suicide: Emotional Responses, Ethics, and Implications for Training Programs Acad Psychiatry, October 1, 2007; 31(5): 329 - 332. [Full Text] [PDF]

Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via HighWire Citing Articles via Google Scholar Articles by Hamaoka, D. A. Articles by Ursano, R. J. Search for Related Content PubMed Citation Articles by Hamaoka, D. A. Articles by Ursano, R. J. Education, Psychiatrists Suicide Related Article

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