MEdIC Series: The Case of the Resident At Risk

2017-01-31T21:29:38+00:00

mental health MEdIC Resident At RiskWelcome to season 4, episode 4 of the ALiEM Medical Education in Cases (MEdIC) series! Our team (Drs. Tamara McColl, Teresa Chan, John Eicken, Sarah Luckett-Gatopoulos, Eve Purdy, Alkarim Velji and Brent Thoma) is pleased to welcome you to our online community of practice where we discuss the practice of academic medicine!

This month, in keeping with our theme of physician wellness and mental health, we present a case of a junior resident who feels completely out of her comfort zone when she realizes that her senior resident may be suffering from depression and having thoughts of suicide.

MEdIC: The Case of the Resident At Risk

By Dr. Loice Swisher and Dr. Mary Haas

Kristin, a second year resident, walks into the emergency department ready for another night shift. She sees her senior resident, Patrick, sitting at a computer across the hall and heads over to receive handover from him. “Hi Patrick, how was your shift today?” she casually asks, noting that he appears exhausted.

Patrick sighs and looks over with bloodshot eyes, “Terrible….. I had the worst day and I’ve about had it with residency.” He leans into his hand and shakes his head. “I might as well just shoot myself.. I want to crawl into bed and just die,” he mutters under his breath, but loud enough for Kristin to hear.

“What’s going on, Patty? What happened?” Kristin asks, wide-eyed.

“Everything that could go wrong, did go wrong… which seems to be the theme lately. For instance, we had an 80-year old with a CHF exacerbation who failed BiPAP. I screwed up the intubation and looked like an idiot in front of everyone in the resus bay. The patient then decompensated and the attending had to take over, nearly had to perform a surgical airway. When I went to tell the wife he had died, she screamed at me and told me it was my fault,” With tears beginning to appear in his eyes Patrick stammers, shaking his head in defeat, “I just don’t think I fit in here.”

After a moment of awkward silence, Kristin responds, “Patrick, everyone has tough days, we’ve all been there. I’m sure if you get some sleep it will make a world of difference.  Why don’t you hand over your cases so you can get out of here and get some rest.”

The remainder of the providers begin to congregate around Patrick’s computer and both residents quickly turn their attention to running the list of patients in the department. After handover, Patrick slips out before Kristin has a chance to ensure he was doing ok. She shrugs it off, thinking he’ll probably be fine and focuses on managing her patients.

Following an uneventful night shift, Kristin heads over to the resident lounge to finish her notes. A fellow resident, Jennifer, is also hanging out in the lounge working on some notes. Despite having 15 more notes to dictate, Kristin can’t stop replaying her interaction with Patrick the night before. While sitting at a computer, she thinks to herself, “something just wasn’t right about how he was acting…come to think of it, Patty has been fairly withdrawn and didn’t seem like himself the last few months”. She grew increasingly worried.

“Hey Jen, have you seen Patrick at all lately?”

“I saw him at grand rounds last week, why?”

“He said something really weird to me last night before sign out,” Kristin says, looking around to make sure no one would overhear.

“Yeah, like what?” Jennifer asks.

“He was telling me about a difficult case and tough encounter with a patient’s wife that sounded pretty traumatizing, and then made a comment along the lines of ‘Maybe I should just shoot myself.’ I’m sure he was just kidding but it just wasn’t right, the way he said it.  It caught me off guard and I wasn’t quite sure how to respond.”

“Hmm, I don’t know. I’ve never known Patrick to have any issues with depression or anything like that but I know his mom’s pretty sick right now and I did hear he had several rough cases in the last few weeks. He’s also in fourth year, working a heavy shift load, doing some administrative work and I think he still has some research on the go. That’s a lot to deal with… Still, we’re a pretty resilient group and I wouldn’t want to open up a can of worms.  We all have bad runs and we push through it.  Were you planning on telling someone about it? If you’re really worried maybe you should give Dr. Harmon (the program director) a call.”

“I don’t know. I don’t want to invade his privacy and make things worse. Maybe he just had a bad day… like you said we all have bad runs.”

The shrill sound of a pager interrupts the conversation. Jennifer looks down, as if relieved. “I gotta run. I have a new consult I need to go see. I’ll leave you to do your notes. See you around.”

Discussion Questions

  1. What red flags does Patrick display that suggest he is at increased risk of suicide?
  2. What do you think of both Kristin’s and Jennifer’s responses to the situation? What are other options for how both of them could have responded, and which approach is best?
  3. What resources are available to residents at risk, and what are the barriers to utilizing them?
  4. If you as the Program Director or mentor are told about this incident, how do you respond?

Weekly Wrap Up

As always, we will post the expert responses and a curated commentary derived from the community responses 2 weeks after the case is published.

This month, our 2 experts are:

  • Dr. Margaret S. Chisolm
  • Dr. Dimitri Papanagnou

On February 17,  2017 we will post the curated commentary and expert responses to this case! After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary. That said, we’d love to hear from you, so please comment below!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

MEdIC Series: The Concept

Tamara McColl, MD FRCPC MEd(c)

Tamara McColl, MD FRCPC MEd(c)

Associate Editor, ALiEM MEdIC Series
Emergency Physician, St. Boniface Hospital, WRHA
Academic Lead, Educational Scholarship
Department of Emergency Medicine
University of Manitoba
  • MJ Brown

    Q4 Daunting to have a new program at UTEM-Nashville with the need to recognize and address just such a distressed resident. Faculty and resident peers SHOULD respond to the red flags but how and when and where-with a medical culture where we have been taught and acculturated to honor privacy,respect the individual and hide our weaknesses. Faculty and mentors should encourage these conversations and support recognizing the need to identify these residents, either by peers or others in the programs. We are our brothers and sisters keepers in the area of mental health.
    I am challenged trying to develop resources for residents and faculty to use as well as recognition of symptoms of the distressed resident.
    Our program stresses peer support-our program director is available as well as mentors have encouraged conversation. watching, listening, recognizing, reaching out with appropriate intervention is our goal-
    it is ever challenging.

    • Tamara McColl

      Thanks for breaking the ice and sharing your thoughts, MJ! There was an excellent discussion during the ALiEM Wellness weak on various resources and methods of integrating wellness activities into the resident program. But I think your comment on the recognition of “at risk” residents holds true – we can institute meditation lessons, massages, various wellness activities but this does not help prepare our residents/faculty when faced with a colleague struggling with mental health. How to recognize the issue? What are the appropriate steps after identification? When do we intervene?

  • Loice Swisher

    I’m not sure the correct etiquette of discussion participation when one has written the case. However, in the months since submission I have learned the terminology to go with the dysphoric feelings accompanying a bad patient outcome- especially one that you cause. This is the second victim syndrome.

    I’m reminded how hard it is to hear ‘intense, brutal honesty’ when thoughts are given sound. It is even hard to know how to respond. So maybe we don’t talk about it hoping everyone will find their own way. Last May, a surgeon’s words in a Humans of New York left me in silence… “And the worst thing that can happen to me is telling a parent that I’ve lost their kid. It’s only happened to me five times in thirty years. And I’ve wanted to kill myself every single time.”
    https://www.babble.com/parenting/humans-of-new-york-dr-la-quaglia-pediatric-surgeon-lose-child-in-his-care/

    I involuntarily gasped at such directness knowing that there have been patients whose trek through my ED kept me up tearfully playing the scenes in my mind again. I wondered how he got through it. How do any of us get through it? Is it enough to say “Yes, I understand.”

    • Tamara McColl

      Always appreciate your thoughtful input, Loice! You bring up such an important point – we all have cases that end unfavourably. They often they sit with us for a while as we replay the events and think of the family. Other than having a close friend/colleague to discuss the case with, what other approaches would you recommend to dealing with this inner conflict?

      • Robert Lam

        Progressive institutions have mentoring programs in place for physicians that are dealing with bad outcomes and specifically second victim syndrome. In the same way that counseling can support a patient through crisis, a peer to peer mentoring program can help significantly help a colleague negotiate that stressful time.

    • Robert Lam

      Second victim syndrome can be a devastating phenomenon if you ask anyone who has been through the process of a malpractice claim. You mourn for the patient’s outcome , doubt your own competency and fear for your professional good standing and reputation. It is no wonder if is one of the most stressful things we can go through in our profession careers.

  • Robert Lam

    In medicine we often adapt a warrior mentality. We value competition, autonomy, invulnerability, power. The part that we have forgotten is the leave no colleague behind. We need to normalize conversations about how difficulty our jobs are and have non-punitive ways to seek help and refer for help. Unfortunately, I had an EM physician training with me who had all the red flags that I thought was appropriately referred and in treatment but tragically years later found out she took her life. It still haunts me that I could have done more to make sure she got the help she needed.

    • Tamara McColl

      Robert, thanks for sharing this painful memory. You’re absolutely right that we as a group need to normalize the conversation and do more to help our colleagues, but most of us struggle with how we can go about doing that. Did your program implement any new strategies on flagging potentially “at risk” trainees, or any new counselling or wellness initiatives?

      • Robert Lam

        At the time, there was not much for wellness initiatives and mental health was outside of the training system relegated to primary care physicians. Hopefully the new spotlight being placed on burnout, mental health and wellness will result in systems that facilitate ensuring that none of colleagues are left behind.

  • Sameed Shaikh

    Q2: Kristen displayed appropriate concern but failed to escalate them to the appropriate level. Unfortunately she confided in the wrong person with Jennifer, who appeared to downplay the seriousness of the situation. Concern for self-harm should be treated like a sepsis workup in a newborn – you do everything until you prove there is nothing serious going on.
    Q3: Available resource obviously vary by local but barriers to utilizing them are ubiquitous – our culture of chin-up and move-on. Nobody wants to be seen as weak, nobody wants to get someone in trouble or jeopardize their carrier trajectory.
    Q4: This needs to be addressed very explicitly in the calm and open environment – without any repercussions. Ideally people from the institution’s mental health/psych team could have a protocol to be utilized in such a meeting along with PD.

    • Tamara McColl

      Thanks for sharing your thoughts, Sameed! Love your quote, “Concern for self-harm should be treated like a sepsis workup in a newborn – you do everything until you prove there is nothing serious going on.” Wise words and ones I will likely repeat with my learners!

  • Michael Myers

    I’ve been asked by Dr Swisher to have a look at this posting and make some comments. I want to preface my remarks by acknowledging that it is always easier to provide sage remarks when one knows upfront that this is a case of a resident at risk. That said, this man gives lots of red flags re possibly being at risk of self-harm with his remarks “I might as well just shoot myself” “I want to crawl into bed and just die” and “I just don’t think I fit in here”. The last one is an example of “failed belongingness” (researched by Dr Tom Joiner) and is serious. In addition, his appearance and behavior, albeit non-specific, are worrying: he looks exhausted, he sighs, he says “I’ve about had it with residency”, there’s a theme of negative thinking eg. lately everything is going wrong, he feels humiliated in the workplace after botching the intubation, he is blamed by the deceased patient’s wife for her husband’s demise, and he shakes his head in defeat. I have treated many patients like Patrick and when a resident is depressed, self-blame is very common. It’s possible that he concludes, irrationally, that the man’s wife is correct, that he really did kill her husband. This can make for a very dangerous situation. His already compromised self-esteem gets even worse.

    Drs Kristin and Jennifer have responded with sensitivity and support but there is more to do to keep this man safe. The fact that Kristin has been worried throughout her shift is important and telling. I’ve always believed we must pay attention to our gut feelings as clinicians. Hers tells her that there’s something amiss with Patrick and she reaches out to Jennifer for validation and commiseration. This is a good thing and reinforces that we must be our brother’s and sister’s keepers in medicine. We learn that in addition to all of the stressors of fourth
    year he also has the worry of his mom’s illness. All of us with good resilience unfortunately are prone to failed resilience when we’re clinically depressed.

    Never worry about invading a colleague’s privacy by reaching out to him/her. Better to save a life. Err on the side of caution vs not doing something. I would suggest that Kristin call Patrick at home immediately and after summarizing her observations/worries ask to meet with him in a private setting – perhaps his home, a quiet coffee shop, a park bench, etc away from the hospital. Let him vent and help him get some professional help. This means being aware of some good resources (from the training office) and even setting up the first appointment and/or accompanying him there. It’s very hard to make appointments when your mood is low and you feel unworthy and a burden on others. Barriers are legion – stigma, cost, accessibility (given the long hours of resident work life), fears of future license questions, breaches of confidentiality, etc. But restoring one’s health and not dying must surpass all of these! I would also suggest that Patrick talk to his training director. This is both for support and advice re resources and perhaps a medical leave if necessary.

  • Alicia Pilarski

    This discussion is so important. Education of a residents and faculty is a first step. We see suicidal patients all the time in the ED, but it’s more difficult to accept a colleague could actually have these thoughts and act on them. No one ‘wants’ to believe that a colleague is hurting or could hurt themselves. Having a process in place, a hotline or some form of resource that all residents know about and can refer their colleague to is also needed. These residents should have suggested discussing his feelings with someone (faculty mentor, PD/APD, mental health provider).
    The second step is creating a culture of support and trust between residents and education leadership. Residents should always feel comfortable going to their PD/APD if they have these concerning feelings about a colleague. This is not a situation where residents necessarily know the whole story and sometimes PD/APDs have more insight to what is going on behind the scenes with a resident. So many times I have had a resident say, “I didn’t know they were going through that” when they find out later that a colleague was dealing with a sick family member. As leadership, we are responsible for these individuals who are going through a very intense period of their lives. Leadership should share cell phone contact info for residents to send a quick text or leave a voicemail during times of emergency and this should be messaged to the residents.
    PD/APD should schedule a meeting with that resident ASAP and ensure someone checks in on him. A phone call, friend who stops over…whatever it is, that resident shouldn’t be left alone with those feelings. Just like we have a protocol for low risk chest pain in the ED, there should be a protocol for a colleague who is displaying symptoms of suicide, second victim syndrome, depression. Ironically, the symptoms overlap.
    Put that protocol in the resident room where they see it everyday. Remind them about it at grand rounds. Send email reminders. Tweet it. Share it with faculty. TALK ABOUT IT. As I type this, I realize we have a lot of work to do.

    • Tamara McColl

      Great insights, Alicia! Thanks for posting!

  • Paul Quinnett

    As a suicide prevention expert, I’ve been asked to comment on The Case of the Resident at Risk.

    I trust this is fictional case, and as Dr. Myers notes, hindsight in these matters is always excellent.

    First, this resident is not just having a bad day. This resident is in the middle of a life-or-death crisis and has just emitted a suicide warning sign (SWS), which is at once clear and unequivocal: “I might as well just shoot myself. I want to crawl into bed and just die.”

    In the majority of fatal suicide attempts, suicide warning signs precede the attempt; to ignore them is to add to the risk, not subtract from it. Suicide warning signs can be taught, and people can learn to recognize and respond to them. Kristen, apparently, has not yet had this training.

    Kristin responds, “Patrick, everyone has tough days, we’ve all been there. I’m sure if you get some sleep it will make a world of difference. Why don’t you hand over your cases so you can get out of here and get some rest?”

    None of this is helpful. In terms of suicidal communications, linguists and politeness theory, this interchange can be broken down as follows:

    1) Kristen did not “hear” Patrick say he is considering killing himself, or she chose to ignore what he said, or to minimize and avoid the implications of the statement. Denial and avoidance are the most common response to verbal suicide warning signs. Statements of suicidal desire and intent are scary (neck hair up scary), and without training, most people do not know how to respond. Research from Sweden on suicidal communications (Wasserman et. al.) found that the most common response to a statement of a desire to die by suicide was silence, as in a Pucker Factor of 9 on a 10 point scale silence.

    2) To move quickly beyond the scary warning signs (we call this changing-the-subject avoidance), Kristen says, “Everyone has tough days.” This is sympathetic but not helpful. Patrick just said he wants to be dead. People don’t kill themselves over “tough days” or we would all be dead by now.

    3) Kristen says, “We’ve all been there.” Again – and unintentionally – she trivializes what Patrick just said he is contemplating doing. For Patrick, he may wonder if “we” means Kristen has been suicidal too, or more accurately, “She doesn’t get how much pain I’m in or she wouldn’t blow me off.”

    4) Kristen’s remedy for Patrick is to get some sleep. Patrick’s second suicide warning sign (also a common one) is also clear, “I want to crawl into bed and just die.” Yes, this could be a metaphor for getting some quality sack time, but not after already saying he is considering shooting himself.

    5) Patrick says, in effect, that he is failing and doesn’t fit in. Isolation, withdrawal, feeling a burden on others, exhaustion, a series of rough cases, an ill mother, a humiliating dressing down by a family member, a growing sense of failure, and now, a non-response to what he thought was a plain enough SOS to a colleague.

    Kristen remains uncomfortable with the SWS she heard from Patrick, so seeks a second opinion. This opinion says, let’s not open a “can of worms” – which translates into “we don’t know what to do here, so let’s move along.” Finally, the old “we don’t want invade his privacy” excuse is rolled out to avoid taking any action, and no one goes back to Patrick to check on his psychological vitals.

    After risking exposing just how much psychological pain he is in to another resident, and with no follow-up contact, no offer of support, no warm hand-off for a consult, or anything that might relieve his unbearable psychic suffering, Patrick has learned the following:
    1. My fellow residents and friends cannot talk to me plainly about my suicidal thoughts and feelings. The subject is too frightening. They don’t know how, or maybe they think I am just weak.
    2. I have just risked my career (by exposing how vulnerable I am) in exchange for a small serving of platitudes. I’ve got a psychological open chest wound here, and I get a Band Aid™.
    3. Apparently no one here (in this institution) knows what to do with suicidal residents.
    4. If my friends and colleagues in emergency medicine cannot recognize my emergency, there really is no hope.
    5. Since I told someone what I was thinking about doing, and if I don’t hear anything more and soon, should I consider a non-response as “permission to proceed?”

    The suicidal mind is already primed to draw hasty, negative conclusions that, in fact, there is no hope and that the only relief from seemingly unending suffering is to end consciousness. Anything we do as friends, colleagues, and co-workers that does not actively confront this state of mind with a bold, positive intervention, support, means removal, and quick access to evaluation for treatment may unwittingly add avoidable risk to the equation.

    In summary, the opportunity to intervene with Patrick was the instant he sent the suicide warning sign, perhaps with the following response from Kristen, “Patrick, what you just said frightens me. I know things have been rough. So, I need to know if you’ve been having thoughts of ending your life. Have you?”

    When thus confronted with compassion and understanding, and in the majority of cases, the actively suicidal person will say, “Yes.” And usually with great relief, as in, “Holy Smokes! I don’t have to go down this road all by myself!”

    But of course, if you confirm that someone who told you they were suicidal is, in fact, suicidal, you have just taken on burden of care you didn’t have moments ago. And now you have to do something.

    This is why – in my experience – it takes a little training, guts, and some handy resources to have the courage to lean into the pain of others and offer to help them through a life-threatening crisis. Frankly, it is easier to offer a couple of bromides, change the subject, and get on with other things.

    That’s my 2 cents.

    Paul Quinnett, Ph.D.
    President and CEO
    QPR Institute
    Clinical Assistant Professor
    University of Washington School of Medicine
    http://www.qprinstitute.com
    Blog at http://www.onsuicide.com

    • Tamara McColl

      Paul, thank you so much for taking the time to share your expertise on the subject – you’ve given us a lot to digest! Much appreciated! You alluded to the Wasserman article as a resource for suicide communication – any other literature you would recommend?

  • Andy G

    It really sounds like Patrick needs help. Though he might be flippant in his comments about suicide, the ER doc in me always thinks “worst first”. I would hope that any leadership would want to know about Patrick’s issues to try to help him and not to get him in trouble. Residents like Patrick can be suffering but be unable to reach out for help on their own. I would definitely want any resident to come to a mentor or APD with cases like this.

    • Tamara McColl

      Thanks for commenting Andy!

  • Lauren Falvo

    Q3-
    It’s not just a question of available resources when it comes to resident wellness- supplying phone numbers and website information means nothing if there’s no reasonable time to act on those resources. I can’t think of many residents who have the energy or motivation to re-hash stressful situations to a hotline on their “free time.” New residents, or persons in larger residency programs (both arguably at higher risk for “slipping through the cracks”) may be more hesitant to ask for help in a new environment, or from a leadership team that they haven’t had to opportunity to bond with, because they’re at increased risk for being misunderstood.

    Added to that is the stigma both from within programs and externally. There’s always the risk/perception that residents may be passed over for leadership positions if they’re thought to be in tenuous mental health. Disability insurance programs take a history of counseling/therapy appointments very seriously and will increase rates/not cover aspects of care if any mental health history is uncovered on their review.

    I personally feel accountability from peers in combination with early preventative actions from residency teams is a much more effective approach to wellness. Don’t wait until despair has set in, give us the tools to prepare and acknowledge our stresses ahead of time.

    • Tamara McColl

      Great points, Lauren. Thanks for commenting!

  • Megan F

    This is such an important case and so important for all of us to discuss. Thank you for bringing this to the forefront Tamara, Loice, and Mary. I agree completely with others that we cannot shove Patricks statements under the rug…however our culture makes it uncomfortable for us to face the problem. We are in a culture of just “suck it up” and move on which tends to make people like Patrick feel more and more isolated. We need to normalize mental health and use terms like suicide warning signs (SWS) thanks Paul! and treat SWS like “sepsis in the newborn” thanks Sameed! The more we educate each other on how to act and how to directly face and identify the problem the better we will become here. I do not believe that Kristin or Jennifer are ill-intentioned at all, they do care about Patrick and want to help, but rather, they feel discomfort in the situation and are unclear how to proceed. I try to tell our residents that its not if but when…meaning that it is only a matter of time before one or more of our colleagues in residency have mental health issues and we must identify resources and how to help up front. I agree with Paul that when faced with a resident or colleague who might be at risk, its an opening to act and intervene.