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.

Inspired by the Harvard Business Review Cases and initially led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the last Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are made available for download in PDF format – feel free to use them! If you’re a medical educator with a pedagogical problem, we would love for you to get involved in the MEdIC series! Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.

Tamara McColl, MD FRCPC

Tamara McColl, MD FRCPC

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