Hi, my name is Rachel Conrad, and I'm here today presenting with some colleagues, including both trainees, faculty, and program directors, about how we can support trainees who have the tragic experience of losing a patient to suicide. This program started about a decade ago, initially stimulated by residents who'd had the experience of losing a patient to suicide and didn't necessarily feel like their institution or program always had the resources that they needed to help them feel supported as they recovered from this potentially traumatic experience. We've been hosting this event at the APA for over a decade now and have had really meaningful conversations emerge. This is obviously our first time to host this program virtually, but we hope that this can potentially be helpful to program directors and faculty who are thinking about how to better support the trainees at their institution, as well as those who've had this experience themselves. We have really interesting resources and research being presented today about the experience of patient suicide specifically and grief among medical trainees in general that I think will be really interesting to stimulate our thinking around that topic. Further, we'll have two incredible stories from trainees who are willing to share about their own experiences to help us think more about how this often plays out in real life. One thing that many programs have identified is that it's challenging to find a system that will accurately identify when the event has happened and be implemented to really support the trainee right after the event. Often these events can unfold in so many different scenarios, settings, inpatient versus outpatient, versus ED contexts, and it's always a challenge to think about how to support the trainees across these different experiences with so much variability. We think that the trainees who have space to share these experiences find it a really helpful experience to process, and we hope that any of you who've had this experience also are able to find support as you process your experience. So first we're going to start with Sheila Kayum, who's going to present some research that I think will be very informative for all of us. Thank you, Rachel. I'm Sheila Kayum. I am a child psychiatrist and the training director for the Child Psychiatry Fellowship Program at Boston Children's Hospital, and I'm also the medical director of the Emergency Psychiatric Services there. So as a medical director of Emergency Psychiatric Services and before on the adolescent and the young adult inpatient unit, I've had a few patients who've died by suicide, and they've ranged from a 13-year-old who died several months after discharge to a patient I took care of since they were 15, who by the time they were 20 finally had a completed suicide attempt. And one of the most recent ones was a 16-year-old that I discharged from the inpatient unit, and they died three days after I discharged them. And when I was coming back and looking at what had happened, I was also cognizant that there was a PGY-1 who'd taken care of this patient with me. And as I was trying to figure out how to best support them, I was very much aware of just how jarring this was for me and how was I going to be available to provide supervision to someone who was during their first week of psychiatry rotation, and this was the very first patient that they'd ever discharged. And so for this, we did a study to really look at how we can best support our trainees. And it's important to consider that right now suicide is the second leading cause of death for older children, adolescents, and young adults in the U.S., and the rates of suicide have continued to increase over the last 15 years, and about a third to two-third of general psychiatry residents will experience the death of a patient by suicide during their training years. So as I was looking at what was out there, one of the things I came across was helping residents cope with suicide on the APA website that talks about common reactions, how to cope, and questions for supervisors were just that, questions like, when do you talk with the family? How do you start this conversation? Would it increase your chances of being sued? The useful references were just around more vigilant and in-depth risk assessments. I found this to be more helpful, which is at the after-suicide toolkit for residency programs in the event that a trainee dies by suicide, but I thought that it actually had more of a framework of what do you do on that day? Who do you talk to? What happens at the weak point? What do you do in a month? I think that's a more helpful framework to think about how we support our trainees when something like this happens. In our research study, we were really looking to elicit and explore what was the trainee's experience, what was it like for the supervisor to provide this kind of supervision, to identify gaps that would help come up with some recommendations and guidelines. For this, we did a qualitative study that recruited 13 trainees and 14 supervisors, and they were from general psychiatry residencies, child psychiatry fellowship programs, and consultation liaison fellowships. This was using semi-structured interviews, and then we did inductive thematic analysis to come to our results. What we found was that there was this general central experience of suicide being a life-changing event in the professional lives of psychiatrists and psychiatry trainees. Although this study really just looked at psychiatrists and their trainees, just to have a similar group of participants, I'm sure that these findings can be fairly generalizable to other specialties as well, where there is an impact of an adverse outcome on trainees. The emotional impact was described as just something that was devastating. It had changes in self-efficacy and sense of responsibility, but on the other hand, there was this general sense of unpreparedness at multiple levels. Then there was these things that either went well or didn't go well that complicated or made the whole experience better that we'll talk about briefly. In general, all the participants, whether they were trainees or they were supervisors, said that the suicide of a patient was really a life-changing experience for them. It had significant emotional impact because they felt devastated and shocked. Even if you thought this was a very difficult patient, it was always sudden when it happened. This was followed by sadness for the patient and the family. It also set apart the trainees that had experienced it from their peers who had not experienced it and created a sense of isolation, that it happened to me, it didn't happen to my fellow trainees. Then there was this change in self-efficacy that the death of a patient by suicide was a big blow to the confidence and sense of competence of both the supervisors and the trainees. This was followed by anxiety and tentativeness and hypervigilance around clinical decision making and documentation. People were really paying a lot more attention in those early phases after the patient's death around risk assessments and asking questions they wouldn't ordinarily be asking. And then there was a sense of responsibility that was something that they did or they didn't do that directly contributed to the patient's death, or that they were somewhat deficient in performing their professional responsibility or duty to this patient. Then we, like this trainee said, what happened? How did this happen? What did I miss? What have I done? Am I really cut out for this? Should I be a psychiatrist? Should I go to this fellowship? Should I come back to work tomorrow? A lot of self-doubt and a lot of guilt and worry. Then we had this sense of unpreparedness, like everybody was not expecting this and they didn't feel prepared before the suicide happened and whatever came up was as a response to the patient's suicide. So the trainees felt that they needed to be sort of inoculated with this possibility of their patient dying before it happens. And it should be a standard part of their training and they should be introduced to supervisors who've had this experience at the start of their training. So they know who they can reach out to if something like this happens to them. And then supervisors felt that they had no formal training on how you manage the administrative tasks that happen after the patient's suicide or how to supervise trainees in the event of patient suicide. So what they end up doing is if they've actually had this experience, then they will draw on their own experience to inform supervision. In terms of programmatic supports, the trainees weren't aware of any policies or algorithms about what their program offered or recommended that they should do in the event of patient suicide. They weren't aware of what personal supports were available to them before the event. And in a couple of instances, policies did exist and they were given in that big folder at the start of orientation and it was gathering dust with all the other orientation materials. So these policies existed, they weren't regularly disseminated or implemented. And then also the notification process was inconsistent. Someone was finding out from one of the social workers during rounds. Someone got sort of a mass email in the department saying that this patient had died. Someone got a call from risk management and that was the first time they heard about the patient's death. Or there was once where someone just left an obituary in one of the trainee's mailboxes and expected them to follow up. And so what this resulted in was that the trainee was left by themselves not knowing who to talk to, who would guide them, and what they were supposed to do next. And then as a system, suicide is seldom discussed as a regular part of institutional culture. And many trainees would say that when they're on the medical floors or they're doing their internal medicine rotations, they are familiarized with terminal illness or end of life care or how you have those difficult conversations. But that conceptualization of psychiatric illness as terminal illness is not always consistently a part of psychiatric education or psychiatry education. In some instances, there was this culture of stoicism or business as usual that led to the trainees feeling torn between taking care of themselves or the duty and obligation that they had towards their patients because we work in very high volume, high acuity environments. And then in terms of formal debriefing processes, like meetings with the risk management or their M&Ms or the root cause analysis meetings, they tend to be very analytical. And the people who've taken care of the patient and the clinical team are having a very deeply emotional experience. And these two are not always aligned. And so formal debriefing processes may not be very supportive of the people in this manner. Then we talked about what are the things that go well and what don't. And one of the most important things that the trainees said that was helpful to them was having a really good relationship with their supervisor beforehand that made them accessible after something happened. And the credibility of the supervisor was very important to them. They wanted to hear from someone who'd actually had this experience rather than having reassurance from someone who hadn't. And then it was valuable, excuse me, for them to hear from someone who that they valued and admired as a really good clinician and see that they too could have had this experience and they were still able to go through it and model that for them. In terms of societal expectations, there was this very palpable tension between what is expected of us as mental health professionals to be able to prevent and predict all suicide and realistically and practically how much of that are we really able to do. And so this discrepancy between the expectation and what is realistically possible from us caused a lot of difficulty and anxiety. And when the perception is that all suicide is preventable, every time you don't meet this standard, it feels like a failure. Then we talked about this concept of shared loss, about how you supervise someone when you too are reeling from the aftermath of a patient's suicide. And supervisors felt like they really were very deeply impacted by the patient's suicide. And they had to juggle this fine balance between being real and vulnerable in front of their trainee, but not overburden them with what they were feeling. And so just being human was important, but ultimately they shouldered the ultimate responsibility for whatever decisions that were made, even though the trainee and the supervisor had both taken care of the patient. And so a lot of the supervisors that we interviewed felt that in those initial phases, they probably were not in the best place to provide the kind of supervision they really would have wanted. And the trainees were also aware if their supervisors were overly dismissive or stoic, that this was their way of dealing with the event. But they were also very clear in saying that sometimes the supervisors were not available and distant and unsupported, like they had to go to the root cause analysis meeting by themselves or they weren't available for supervision afterwards. Once there was a trainee on neurology who the neurologist came and said, you know, that patient we saw last week, they just blew their brains out and then walked away. And so the trainee was left by themselves trying to figure out how they get back to their own program and ask for support. And so in instances where the trainee felt unsupported, this really complicated the relationship in the trainee being able to access that supervisor for the future. In instances where the trainee felt that their supervisor was probably having a more difficult time, they felt like going to a different supervisor who'd had a similar experience but was removed from the case was often more helpful. And I think in terms of societal expectation, this really captures it well, that I think as a culture, we buy into the notion that we're supposed to let, we're not supposed to let anybody die and it's our fault that they do and that we'll get sued. The notion of culpability is very much built into the idea that we have to look okay, make sure my documentation is good, that I asked those right questions and if I did all that, I won't get sued and I'm okay. That's not sufficient. I think it hurts our capacity to care for people in these situations and undermines our supervisory relationships. We have to grow beyond the notion that we did something bad when we couldn't prevent it. Death is part of what we do when we trainee. And I'll end with this, and I think this is why we're all here today, that this will take a place in your life and it'll have purpose, it'll have meaning, and it'll feel a little, you'll never forget it. And it'll only strengthen you in the end if you let yourself think about it enough and feel enough about it, you'll be a better psychiatrist. That's how you do honor to the person who killed themselves. Thank you. And I'll pass on to Courtney Ferguson, who will talk about grief and complicated grief in medical students. Thank you so much. Hi, everyone. My name is Courtney Ferguson. I am a medical student and a public health student at the University of Pittsburgh. I'm currently working with Eva Rachel LaFrosse and Sarah Stahl. And we recently did a study to investigate medical students' personal and professional experiences with loss, grief, and complicated grief. And to start a little with a little background, as many of you may know, burnout and mental illness are quite common amongst physicians and medical trainees, with the prevalence of depression being much higher among medical students than the general population. And some studies try to investigate what could these causes of burnout be. And a few studies had investigated and found that grief may be a contributing factor to burnout because of the depression, anxiety, stress, and physical symptoms associated with loss, but also thinking about the environment within medicine. There have been a few studies that describe the culture of medicine as isolating and stressful, which may also amplify the physical and emotional effects of grief in medical students. And then also thinking about this from an education purpose perspective, and the lack of education on the reality of death may actually decrease empathy and depersonalize doctor-patient relationships, which ultimately deprives medical trainees of the experience to address their own emotional responses to death and to grief. So for our study, we had three aims. And one was to examine the association between bereavement and students' comfort levels and their beliefs. And then our second was to compare emotional and behavioral health problems in both students with and without probable complicated grief. And third, to perform a thematic analysis to illustrate the damaging health effects of grief that might be unique to medical education. So we did a cross-sectional survey asking students to answer questions about their comfort levels addressing grief, their beliefs surrounding grief, and formal grief training, experiences with lifetime loss, details regarding the people that students have lost. And we also investigated complicated grief symptoms using the Brief Grief Questionnaire, which is a scale that identifies whether or not someone might have probable complicated grief for you to investigate further. And then we also asked questions about emotional and behavioral health problems. On the qualitative side, we conducted a reflective thematic analysis of 27 medical students' free responses. And we identified seven themes and a few sub-themes for each one. So a little bit about our demographic. So 103 medical students completed the survey. And a majority of them were first years, but we still got a lot of responses from second year, third year, and fourth year students, and a few from leave of absence. Of note, of the students, a majority of them had reported some experience with lifetime loss, with only 30 out of the 103 saying that they have never experienced bereavement before. And then for the number of people that students lost, 23 said they had lost one person. However, a majority of students had lost multiple people throughout their life. So before we go a little bit into the results of the comfort levels and beliefs, I just wanted to explain to you what we asked. And so we asked comfort in students feeling comfortable discussing the death of a person that a peer or a patient lost, but also their comfort level with supporting a peer or patient who is experiencing grief. We asked them several different types of questions for beliefs, and some of them were about, if they knew how to act when someone was grieving, they understood what a grieving person meant, if they knew what resources to provide to a grieving person. And the last two are about medical schools and education, whether or not medical schools should support grieving students, or if every student should receive grief training. So from these comfort levels and beliefs, we compared bereavement to non-bereavement. And what we found was that students who experienced bereavement were a lot more comfortable providing grief support than non-bereaved students, and had stronger beliefs about the statements that I mentioned in the previous slide. But they were shown to have less interest in receiving more grief training than non-bereaved students. So next, we also asked questions about complicated grief. And of note, we found that students who experienced more, like higher numbers of bereavement or lost more people, were more likely to screen positive for probable complicated grief. As well as students who experienced more behavioral and emotional challenges, they also were more likely to screen positive for a complicated grief. Those are some of the more some of a few of the findings that we've had. But I want to move on forward to themes because I know that we today are talking about patient suicide, especially within the resident perspective. But I've been grateful to come to talk to you guys a little bit more from a little earlier from medical students' experiences. And so basically in the themes, this was a time for students to just tell us their experiences with loss and how it's impacted them in medical school. And we identified seven themes. I'll just go over them briefly, but I want to just go to the quotes right after. So one was reactivity to personal loss, two, importance of grief education, three, how personal loss related to medical school, four, palliative and hospice care, five, impact on patient care, six, lack of empathy in medical culture, and seven, lack of support from medical institutions. So for one of the themes, we had reactivity to personal loss. And one of the students did not say that they were having suicidal ideation. And they explained not quite suicidal ideation, but passive death thoughts, such as if that car happens to run a red light and hit me while I cross the street, that wouldn't be so bad. Another student talked about their dying grandparent and described saying, I avoided calling him in the months before his death. I was uncomfortable and blamed being busy at school. Then there were some students who also gave stories or explanations of how their personal loss related to medical school. And one student said, my grandfather was diagnosed with metastatic cancer all over his abdomen and passed away several months later. He donated his body to science. This was around the time we completed anatomy. And I kept thinking about med students in Florida, exploring his cancer-ridden body while chatting with each other about their weekend plans. Another student was talking about their relationship with their grandmother and how it impacted their ability to study. And so they said, it was really hard for me to focus on school since my grandmother was really close to me and brought me up as a child. I feel like I just never learned GI well because of it. And then there were some conversations about impact on patient care and the importance of grief training. One student said, dealing with grief is something we are never taught much about during med school. Handling personal grief is challenging when you have responsibilities and patients to care for. We are never really taught how to cope with death of a patient we have become close to. Another student said, from a patient care perspective, it's very important for medical students to learn about grief and death. Fear and discomfort with the topic leads to doctors to abandon patients in moments of need. And this last quote was an excerpt of a longer response. But this student had expressed a lot of challenges while in medical school and also shared that they didn't receive a lot of support from institutions. And they wrote, if one is grieving, one is lucky. It means one is not dead. If one is not dead, one can still work efficiently as a physician or participate in healing as a patient. That is the bottom line. That is all our medical school, hospital, and research institution need to care about. And incidentally, all they do care about. They go on to talk a little bit about the lack of infrastructure in place for institutions to support grieving individuals, both patients and medical trainees. And so my conclusion is, you know, one of the things that's really important is that we have a lot of data on complicated grief. And we have a lot of data on grief training for medical students and trainees. But we don't, we haven't really investigated a complicated grief. And what's interesting is that there are several risk factors for complicated grief, one of which is pre-existing mood disorders. And with pre-existing mood disorders being prevalent within our population, it would be pertinent for us to learn more about complicated grief because it has the potential of being more prevalent among medical trainees than the general population. And I think that some of the take home messages from this is that there's more work being done on training, but I think that students are showing that they want to learn more than just grief counseling skills. And they want, they want to be comfortable addressing death. They want to be comfortable addressing grief. They want to be able to find ways to cope with their own personal experiences, especially when they might be re-exposed to such experiences later on. And that's all I have to say. Thank you for attending. If you have any questions, please email me. I'm going to send this over to Annie with a personal story. Hi everyone. My name is Annie Yeh. I am an assistant clinical professor of psychiatry at Tulane University in New Orleans, where I also did residency. And today I'm going to share with you a story about a patient lost to suicide that I had during my second year of residency when I was on the ED and CL rotation. So I lost my first patient to suicide during the middle of the second year of my residency. My patient was just a young teenage boy who had just turned 13 and had aged out of the pediatric healthcare system. His mother had brought him to the pediatric ED only to have them say he's 18 now and we need to transfer him to the adult ED about 20 minutes away. I didn't know it that day, but the course of events that would unfold from there would affect me deeply throughout the rest of my psychiatry training. The wait for my patient transfer was excruciating. And I remember staying past my shift to accept this patient whose chart I had already reviewed obsessively. The 18-year-old arrived with his mother. After they were roomed and examined by the ED staff, I went in and spoke first with the young man and then with his mother. If I had made my assessment strictly off of just what I had read in this young man's chart alone without speaking with him first and then with his mother and then later on with his psychologist with whom he had been in both individual and group therapy for the last year and a half, I likely would have committed him. However, during the two-hour or so exam, he voiced no suicidal ideation or plan, was able to reason with me in a thoughtful way, and initially what had started off as an altercation between mother and son over truancy at school mellowed into this young man acknowledging that he had anger issues, which he wanted to work on, and his mother acknowledging that she wanted to work on developing a closer relationship with him. The three of us spoke with the young man's psychologist who also stated that he didn't believe the young man needed to be hospitalized at that time. And in fact, that inpatient hospitalization may actually be detrimental to his ongoing work and the therapeutic relationship that this young man has been or had been building with his mental health care providers over some time. So together we formulated a plan for discharge with the young man scheduled to see his psychologist the next afternoon. So the next afternoon I was, you know, finishing up my clinical duties and it was a didactic stay. So I, you know, had my phone on vibrate because I was deliberately waiting for the psychologist to call me and let me know how things had gone with this young man. I received a call about midway through my didactic session only to find out that this young man had never made it to his appointment. He had in fact committed suicide, taken his life prior to that appointment. And I remember just being completely stunned. And at the time, you know, over the phone call, I could hear the anxiety in the psychologist's voice. And instead of, you know, talking about the incident, I think he was thinking more about the legal ramifications of what could happen. I had absolutely no idea how to handle the situation because as residents, you know, we never been briefed at that time on something outside of make sure you always assess for suicidal ideation plan, you know, previous history, which had been drilled into me since medical school. But that's all well and good until you're actually a trainee facing an actual experience with the patient suicide. So I remember feeling like a deer in the headlights, I'm exposed and vulnerable without a clue as to what to do next. I was purely acting on instinct. And I remember reaching out to my program director, letting her know what had happened. And together, we called my supervising attending on the case and talked through the events that had happened since his discharge. You know, my attending was a while he was my CL attending at the time, and he shared with me that he had had patient suicides occurred to him. And at the time, you know, I think he meant it to be comforting. But I was also sort of grappling with my own emotions and my own self doubts and feelings of guilt that were creeping in. I remember, you know, immediately, the thoughts that were running through my head were things like, had I missed something? You know, what could I have done differently? And I remember going home that night and reviewing my notes on the case, obsessively, you know, reading them two, three times and going over our entire, just the entire encounter ad nauseum. I returned to my rotation the next day, and was, you know, still in the ED, still on the CL service. And it was towards the end of my shift. And I got a call from one of the, you know, one of the phones in our ED triage area. And I thought it was kind of strange because we typically don't get phone calls in that area. So I picked it up. And on the other line was this young man's mother, who was in tears. I had, you know, probably three more patients to evaluate in the ED. And just my mind just went blank. And I remember sitting there with the mother for probably 30 minutes, but it seemed like much longer than that, listening to her and eventually crying with her, which I don't know if that was actually the right thing to do, you know. And, you know, there wasn't space to really talk about this with my peers. And, and when it came up in conversation, I think some of my peers were kind of horrified that something like this could have happened to one of their fellow trainees. My attendings were supportive and suggested that I take time off. But ultimately, I threw myself headstrong into work, almost, you know, full throttle, because I just felt like I couldn't sit with my emotions and think about what had happened. So it's almost been three years since this incident happened. And I still get emotional talking about it. I am at a point where I think I feel comfortable, you know, and even empowered to be able to share some of my experiences, but that's taken a long time. I remember serendipitously coming to this specific symposium about two years ago, when the APA had its last in-person visit, or in-person meeting in San Francisco, and meeting this wonderful and courageous group of trainees who shared their experiences and program directors who supported their trainees. And, you know, even in, in, in talking about the experiences, and also creating a safe space and a structure to talk about this, so that other trainees can benefit. So from that experience, I was empowered to talk about my own experience within my training program as a third year, towards the end of my third year, so almost a year and a half after I had lost my patient to suicide. And I did this in a pretty big forum of the Grand Rounds presentation that every third year resident is expected to give. And the title of my presentation was the aftermath of patient suicide, how do we support resident trainees? And as a fourth year, I felt like I owed it to the incoming trainees to talk about this and to create a platform where we could talk about patient suicide, not have it be this taboo subject that we, you know, train our trainees from medical school to conduct a suicide risk assessment. But, you know, what do we do with that in the event that it actually happens to one of us? So, you know, this work is still ongoing. But I think one of the things that I am kind of left with that still haunts me about this case is, I oftentimes do lament that I didn't keep in touch with the mother of my patient who took his life. You know, I was, I had talked to risk management as part of the legal aftermath of all of this, which was something I didn't expect to have to do, but was lucky enough that my attending came with me. And, you know, one of the things I was counseled on was to not have communication with survivors of suicide. And I oftentimes wonder how she's doing, because as a mother now myself, I can't even imagine the tragedy of having to lose a child. So, thank you for letting me share my story. And I know we're going to have some discussion afterwards, but I'd like to turn this over to Maggie now. Hi, everybody. I'm Maggie Schneider. I am a current Child and Adolescent Psychiatry first year fellow at Boston Children's Hospital. And I lost a patient to suicide during my inpatient rotation in my PGY2 year. And the experience was, I think, as we've heard from Annie, extremely formative and extremely difficult. And I'm honored to have the opportunity to talk about it today with you all. So, my patient, my experience is very different from Annie's in that my patient committed suicide on the inpatient unit. And I think that that was a, it was an important aspect of my experience in that I did not have the experience of in any way being alone with this loss. I found out about it very quickly after I had lost my child. Very quickly after it happened from the attending that was on call. It happened over the weekend for the attending that was on call that day, called me on my cell phone pretty shortly after it happened and let me know. And then almost immediately after that, I got a call from the chief resident asking if there was anything they could do to support me. So, I think I was very fortunate to be in an environment that was extremely supportive and felt extremely held. But it was still just a devastating loss. I think what Annie says is completely true in that you naturally go through the thought process of what could I have done differently? Should I have put this person on constant observation? What should I have done? Could I have done anything to keep them safe? Why didn't I expect this to happen? And I think some of those guilty feelings are perhaps magnified by the inpatient setting in that I feel like that's the environment in which we are most responsible for people's safety. And in this case, we failed to achieve that. One of the important issues that people have brought up is taking time off. And I was completely confident that I wanted to go to work the day after. So, the patient died on a Sunday and I had no question about whether or not I wanted to be there on Monday. It was very important for me to be there. And I think it was important for me in my healing and my understanding of what happened in myself to be with the community of other people that worked on the unit on that day because it was a hard day for, I think, absolutely everyone. And to be able to talk through the experience with the medical student that was on the case, the attending that we had worked with, other residents that had worked with the patient, the nursing staff, I think everyone was devastated. And not that you wish for a And not that you wish for everyone else to be devastated, but seeing other people having that experience definitely made me feel less alone. I did, however, take the day after the day after off. And I'm so glad that my program kind of gave me that opportunity because I really did need some time to process on my own and to reach out to my family and reach out to my own therapists to have some space to really try to understand how I was feeling and what would happen next. I think there's a huge challenge in any situation when you lose a patient in thinking about who and how you can talk about it with and how you can process it. We had the very good fortune of having a couple of groups with that goal organized on the unit that were extremely helpful to me. But actually one of the other things that was extremely helpful to me is just the number of faculty members that I knew that kind of reached out to me in the days after it happened to let me know that they had had a similar experience at some point in their careers and that they were available if I wanted to talk to them. I only took one or two of the many people that reached out to me up on that offer but it was incredibly valuable to me to hear that other people that I truly respected and other people that I sincerely believed are excellent psychiatrists had also had losses. And I think other people that I sincerely know are excellent psychiatrists were involved in the care of this patient which helped some with the loss and the self-doubt. One of the things that I really noticed about myself in the process of understanding and the process of recovering is how it changed the way I think about other patients since then. And in particular for the, you know, for weeks afterwards I felt my felt myself thinking, spending a lot more time thinking about whether someone should be on 15 minutes checks or five minute checks or constant observation than I ever had before. And that's still something that I think I probably put more thought into than a lot of people might. And just kind of maintaining an awareness of this patient and his loss in my mind. In the after process we did have a meeting with this young man's family, with his mother. And one of the things that was really hard about that situation in particular is that he had initially allowed us to communicate with her but then had asked us not to speak to her anymore. And so she had known he was in the hospital and had been very confused that we had stopped calling and giving her updates because he had asked us to stop calling. And so I think that that was, that was a big part of the process. And so I think that that was kind of particularly overwhelming to go into her with this incredible feeling of sadness and this incredible feeling of loss and have to explain to her why I had stopped calling her when previous people had called her before to tell her what was going on. And I think always in any situation the communication with the family in this situation is going to be incredibly challenging or heartbreaking. And that meeting was one of the, one of the saddest experiences in my residency and I still, I still think about it from time to time. Overall, I think kind of the most important thing that I took away from my experience is the incredible value of having lots of different venues of support coming out of it, that I had support from program leadership, support from mentors and supervisors that had been involved in this specific case and mentors and supervisors that weren't. And then also really great support from my colleagues, my fellow residents, two of my fellow residents had seen the patient in various locations before, one that had met him overnight and one that had seen him in the emergency room. And so while I had been involved with him for two weeks at the point that he died, there were a bunch of other people that had also had contact with him and cared for him. And I think that was important. Since that time, I have made an effort to be aware of when the same situation or similar situation happens to other trainees in the programs that I've been affiliated with. And unfortunately it has happened. I think the statistic that 30, 60% of residents will experience this at some point is probably true. And it's been powerful for me to be able to take the opportunity to offer, to be a support to other people going through it and to talk about my experience, both in these larger forums and one-on-one with people that have lost a patient. It's a very individual experience, but there are, I think also a lot of commonalities between different people's stories and trying to understand the ways in which we can support each other and the ways in which we can support trainees that are behind us in the timeline of training has been a valuable way of me kind of thinking about how I can use the experience to create meaning in the world, even though it's something that's very difficult to live with. Overall, I think that losing a patient to suicide is an incredibly difficult thing and it does absolutely make you question all of the choices that you made for that patient and also kind of all of the choices that you made leading up to that moment. But the experience overall, I think has also made me a stronger psychiatrist and made me a more thoughtful psychiatrist. And my hope is that I can continue the things that I've learned moving forward in order to kind of honor the patient that I lost. Thank you. Thank you all so much for the incredible contributions that you've each made today. I think research by Gila and Courtney, it's just such critical topics and it's kind of shocking how little that we know about these potentially traumatic experiences during medical training in a population that we know is so vulnerable to burnout and demoralization, but it's really inspiring to hear what great work that each of you is doing, that you're really trying to contribute to the literature. And thank you so much to Annie and Maggie for sharing so openly about your own very painful experiences, losing patients. We are really grateful that you're willing to speak with us about those experiences. So I'd love to hear from the panelists just a few of your reflections so far on the conversation today, anything that struck you, anything that came up for you so far in the presentation. Sid, do you wanna share a little bit about your experience so far? Sure, and thank you for all of the terrific discussions and narratives. Gila, I hope I'm pronouncing it right. Thank you for reminding us that suicide is an occupational hazard, it's a universal experience that if you are not one of the 30 to 60% of residents who experience it, you will a little bit later in your career. And not only are residents often unprepared to deal with it, but so were their supervisors and programs. We need to do better. One way we could do better is having each program at some point in the year, maybe not in July, but perhaps by September, have a symposium or a grand rounds exactly like this, where people talk about their own experiences, not only residents, but also faculty. Thank you, Courtney, for reminding us about how important grief is, and that we are human beings and medical students and residents and faculty are human in their grief as well, and often don't have a lot of education in terms of allowing them to allow themselves to grieve. And I think this is an important part of what we need to do. And then thank you for Annie and Maggie for those wonderful narratives. Annie, just a couple of comments on yours. One that you mentioned, how important it was to you two years at this symposium to hear the narratives. An important part of the symposium two years ago was the about 40 minutes or so of audience participation in allowing people who were there to share their experiences, talk with each other. We had small groups. We don't have that this year. So I encourage everyone listening in to reproduce it in your own programs. Go back to somebody and talk about your experiences. Use this as a trigger to talk about your own experiences with people you trust in your own programs. Can be your training director, a supervisor, a colleague, don't forget your spouses and significant others as well in terms of talking about these kinds of issues. You mentioned also Annie that suicide is taboo and hard to talk about. And we need to think suicide is the end stage and consequence of many of the illnesses we treat. And we treat malignant, often fatal illnesses. And oncologists don't consider death taboo. They don't consider a failure when somebody dies. It's a risk you take when you treat patients who have fatal illnesses. And so the suicide of a patient is not a failure but it feels that way. And both Annie and Maggie talked about the guilt feelings and the doubts that consume them in the aftermath of their patient suicides. And those are, they're not, it's not bad to have those feelings. It's human to have those feelings. We all have them. And allowing ourselves to be human, to have those feelings, to embrace those feelings, to talk about those feelings is so incredibly important to continue to grow and continue to be the best psychiatrist we can be. I have about a thousand other things I'd like to say but I'm going to turn it over to, I think, Joan next and then probably deep back after Joan. Well, it's been wonderful to participate and I want to congratulate all the speakers. It's just great to hear and some really interesting points that you made. You know, this is, we've actually been kind of working on this project for more like 15 years and I think it keeps kind of maybe going down a little bit and then coming up again as a topic in psychiatry and different programs because it is, as Sid said, taboo and it's a very painful topic for most people to discuss. So it's kind of human nature and natural for people to want to avoid it. And even, we think even in our own field that we wouldn't avoid our worst case scenario but we do too. So our efforts in this area actually need to be effortful and that we have to override the natural human tendency to want to avoid thinking about it. And that's, I think, one of the things the symposium has done over the years. In terms of just in a nutshell of the things that are common and I think you heard commonalities in Annie's and Maggie's stories, the initial shock and kind of numbness and how could this happen? And then the grief and then what did I do? Did I miss something? Did I, right? Those are very common, but the, and there are some things that should be done in every case. I really feel that in an ideal world, the, an attending supervisor or the program director should be the one to tell a resident about the patient's suicide and be there. Sometimes that can't happen, but you can set up things in the department program so that the program director has to be notified immediately if a resident has lost a patient and then they can reach it out. It takes a long time, you can set that rule but it takes a while to get people to adhere to it. But that makes a difference. And then another thing I learned really early on is that not just to notify the resident who last cared for the patient, but to notify every resident who had laid hands or listened to that patient so they don't hear about it in the elevator. And the time off, you pointed that out so beautifully, both of you, that almost everyone wants to be back at work because to stay home kind of is associated with shame and you've done something wrong. And so I think it is very important for people, for residents in most circumstances to be back in the community of psychiatrists. At the same time, you're gonna need more time to reflect on that. So there's no real rule book for how that happens, but just to allow for time for that to happen. And then, Annie, you told a story, I think, where risk management said, don't talk to anyone. Is that right? Yeah, they were dead wrong, let's say. They really were. And I think Sid would agree. This is how they are taught in whenever there's an adverse event in the hospital. But in this situation, we know that most families, majority families do wanna hear from us. And if they do hear from us, they're much less likely to pursue litigation. And so it is, and what I love with Glenn Gabbard's saying, when in doubt, be a human being. You definitely wanna reach out to the family. They may not wanna talk to you, but at least you've reached out, right? So- Joan, can I ask a question? Yeah. Can I ask it both to you and Deepak and Rachel? All of you can think about it. So in terms of reaching out, both Annie and Maggie talked about their ongoing regrets for not having had enough of the conversation with the mother or the significant other. And I wondered, as each of you told the story, is it too late to say, hey, I was just in a symposium talking about when psychiatrists lose patients to suicide. And I was thinking of you and I was thinking of, John or Joe or whatever the name of the person is. And I just wanted to check in and see how you're doing. I wonder, I've never done that myself so long after the fact, but I wonder if it's something you could do if you chose to. I don't see why not. If I were the parent, I would feel grateful. But again, they could always say no. Sure. And Gila can talk to this more, but one thing that we hear a lot in pediatric palliative is that parents are very afraid that their child would be forgotten. And Gila worked in that space for a long time, so knows more about that. But I think for the family to know that you still think about their child, I think would make a lot of difference to them. Yeah, that their child in a way lives inside of you in part. I would agree with that. I think a delayed outreach in this kind of case, it's obviously not counterproductive. Now, if the family is not comfortable at a certain point and individuals may have different kinds of reactions, then we can obviously take that feedback. But reaching out after an interval, I think what it alludes to is another theme that's emerging here as we hear these very powerful stories is this shared experience. In very limited scenarios also, an individual who died by suicide ends up touching at least eight to 10 lives. And in this day and age, it's safe to say that actually more people get touched by each and every individual who died by suicide. And we are one of those as treatment providers, as their psychiatrists and their child psychiatrists, almost like an extension of their family in that sense, if we have long-term treatment relationships. So what happens here is the kind of feelings that we are going through, let's say six months or 12 months after a patient died by suicide is perhaps something the family might also be going through. So this kind of shared experience, I think this needs to be acknowledged at some level, both at our own individual level, but also within our institutions. Like this is not something that just happens from a very medical legal viewpoint. It does have a personal impact on individuals. As we are thinking through things, and again, wonderful patient stories that came up here. Another thing that comes up is, and this is your earlier point, that there are a few topics that all of us are anxious about, or all of us probably can benefit from when it comes to knowledge. And that's just us being proactive about how to situate these conversations in our training curriculum, in our medical school curriculum, so that more and more people feel comfortable and are equipped with knowing some of the very basic facts, like the fact that most people in this profession will have to encounter this one way or the other. So it kind of normalizes that experience to an extent that it's okay to have these discussions. So rather than reacting to this and going in with some sort of an ambitious approach, can be proactive, make sure that folks have that necessary information, that they do understand some of those necessary tools related to risk management, some of the things that we just discussed about outreach, that it's safe to do that. Yeah, I'd agree with that. And particularly one of the things that we found was that the trainees felt like if at the start of their training, and this is a consideration for smaller programs, that they may not have faculty who've had the experience of patients dying by suicide, but there may be other clinicians or people in the community who have. And if those people are introduced upfront, not only does it sort of destigmatize that patients can die by suicide, but it also sort of identifies the people around you who've had that experience that you can reach out to when that happens. And those people have demonstrated vulnerability in making themselves reachable and approachable should you need that. And I think that's something we really need to do for our trainees upfront. You know, there are other positions, particularly proceduralists who lose patients during procedures, and sometimes there's an error, sometimes they're not, they both have an impact on that person. And they have similar or can have very similar reactions. They don't talk about it very much, but they can. And I remember one young neurosurgeon saying to me, they never told me about this in medical school, what it was going, what it would feel like when I had a bad outcome. I wish I had known. And the same, you know, wishing I did this to him. And so there's similarities, but suicide is different. Death by suicide is if a patient took his or her or their own life. And one of the things that's hard for us to talk about is the morbid sense of betrayal, you know, that the patient, we're doing our best to help the patient and, you know, putting a lot of our heart and soul and then they took their lives. And I think that that's what makes suicide different, I think. And yeah, there could be a sense of feeling inadequate for that patient or that. Yeah, Joan, I think that's true. Betrayal is one of the things that makes it different. But can you imagine the degree of betrayal, the parents of the child feels. And it's such a universal response when someone dies by suicide. And I think it's as though we as psychiatrists should know how to predict it, which we can't, and always be able to prevent it, which we can't. And think that our love should have been enough to keep them going. But when somebody's in a suicidal crisis, it's not enough. Escaping the pain is really the issue. Even though they may feel very loved by their family, by their psychiatrist, by others, it's just not enough to sustain somebody in a suicidal crisis. But we as psychiatrists, because of our humanness, feel that sense of loss, betrayal, we should have done better, we could have done better, shoulda, woulda, coulda, if. And I think those are, again, they're normal responses, but somewhat misplaced, because we're not omniscient and all-powerful. I think that we haven't mentioned the Collateral Damages Program yet today. So that was developed by Sid and Joan and a few other program directors, as well as Glenn Gabbard, maybe 10 or 15 years ago. And it's available now on the ADPERT Toolbox. I think it was initially funded by the National Suicide Prevention Foundation. No, it wasn't, but they helped with it a lot. It was funded by, yeah, there was a private foundation that we had that funded it. But the AFSP has been very helpful. And so for training directors, it's available on the ADPERT website. For others, it's available through the American Foundation of Suicide Prevention. So they will provide that to other programs or individuals, as long as it's being used for educational purposes. Sid, how does the foundation provide it to other individuals, such as trainees? They send the old DVD. They send the old DVD. Right, as opposed to ADPERT, which has it online and available that way. Good to know. And Sheila, do you want to share with us any other resources that you would recommend for programs or institutions to implement or to consider either for both prevention or postvention? So just some suggestions for programs is really based on what we heard today, that we have to prepare our trainees, but we also need to prepare our faculty, both in the administrative procedures, as well as how to supervise. And one of the things that most of the trainees said was that really a thoughtful disclosure of a supervisor's own experience is really helpful because not only does it normalize and diminish the sense of isolation, but it also gives a framework for the training which they can then process their own emotions based on what they hear. And then also, I think it was brought up is that we really need to streamline the notification process by developing policies and postvention protocols. And then also that we have to support each other, figure out what are our internal supports, what are the external supports, normalize the experience, and also knowing that the root cause analysis or risk management meetings need to acknowledge the stress of the event for that whole clinical team. And then also taking a moment to pause. We may not always have the time in the moment in our busy clinical days when we hear about a patient's death by suicide, but really acknowledging it and then setting aside time for later can be really helpful even if you can't address it in the moment. And then I know both Maggie and Annie brought up accommodations and workload that they really wanted to be immersed in their work, but trainees always feel that they don't wanna be the ones asking for support, but if the program provides it, then they can take it or leave it based on whatever they need in that moment, but the onus is taken away from them. And it also extends that feeling of being cared for and supported and held in that moment. And then also periodic check-ins because this is not just in that moment, it takes time, it takes a lot of time, it is a process of mourning and loss just like any other. And so through that whole year, just having regular check-ins, even if you're just having coffee is something important. And then again, if they need referrals for people outside the program to talk to or supervisors within the program, we need to do that more proactively. Thank you so much, Sheila, for reviewing those recommendations. I'm really grateful for everyone who contributed today. Thank you again, Sheila and Courtney for presenting really interesting research in such a alarmingly under-researched area, but it's wonderful to see really high quality work evolving in this area. Hopefully the literature will continue to grow and it will continue to become an area of interest of institutions, medical schools, and training programs. And again, thank you to Maggie and Annie for sharing their stories. That's always the most potent part of this experience. And thank you, Sid, Joan, and Deepak for your commitment to this area and working on this area for the past decade and a half. All of those of us who've lost patients to suicide, including me, have really found this program to be a really touching experience and formative in our recovery from this potentially traumatic experience. ♪♪

supporting medical trainees

lost a patient to suicide

residents feeling unsupported

research

grief education and support

programmatic supports

emotional impact

ongoing support

challenges in reaching out

recommendations for programs

supportive environment