Addressing unexpected loss during medical residency

Program directors are prepared for many eventualities, but the sudden death of a trainee from an accident, an acute medical event, or suicide can come without any road map for response. Faculty must manage practical issues and their own emotions while at the same time helping residents deal with the loss of a peer. When Chandlee C. Dickey, MD, found herself in this situation in 2016, as the training director of the Harvard South Shore psychiatry residency training program in Boston, she initially turned to PubMed for advice but came up empty.

“What we did in the initial days and hours after the event was more based on good common sense, and talking with close trusted colleagues locally, and ‘seat of the pants,’” she said.

After some time had passed, she and her associate training director, Barbara Cannon, MD, reflected on what they had learned and published a paper in the August 2018 Journal of Graduate Medical Education, offering a potential framework for other programs that might someday need it. The framework covers gathering resources, breaking the news, talking with the deceased's family, and handling memorial services, among other topics.

Dr. Dickey, who is now chair/chief of the department of psychiatry at the Schulich School of Medicine & Dentistry at Western University in London, Ontario, recently talked to ACP Internist about the unexpected aspects of managing grief and the importance of building a strong community.

Q: In 2016, what did you do first? How did you tell trainees what had happened?

A: The key was to send out an email broadly that I needed all the residents in a particular location by a particular time and that the expectation was that the residents, except for those on call, would not be returning to clinical duties. To get an email like that from me would be very unusual—and it was very short and very clear—so it let people know that something was up. I am grateful to all of the faculty as they responded without question.

I put all the chairs in a massive circle because I wanted everyone to be together. I gave the news slowly, and we passed a microphone around so that if someone wanted to say something, they could. They wouldn't be overshadowed by others' voices. Another thing I did was express my anger, that it was OK to be angry at this person who died, and to express my sadness. I expressed my grief and my worry for the other residents. I modeled the kind of emotions that others might have, very intentionally, which I think allowed others to express what they needed to express.

Q: How long did the meeting last?

A: That meeting lasted two hours. I allowed for a lot of quiet time, because with the quiet, other people spoke up. It seemed to me that that meeting would define how things would go, future messages, and what the residents experienced. That was critical, having absolutely everyone together, free from future responsibilities for that day, with time to be together and time to build our trust and community.

Q: You talk in the paper about disenfranchised grief, which you define as grief that's not freely expressed and even repressed, and how the effects of a trainee's death can come up after you might expect it. How might that manifest itself?

A: I heard from a resident or two that it became very difficult to know how to support people. Two or three weeks after the death, a caring faculty member probed residents' feelings instead of teaching during didactics and it was a disaster. Because the residents didn't want to delve into their feelings right then. They wanted to learn about motivational interviewing or whatever the topic of the day was. It was not very easy—in fact quite difficult—to know with whom do we need to intervene, when, and in what way.

You really have to know your team, and a lot of leaders don't necessarily know their team that well, and people who are grieving silently aren't necessarily going to tell you. I think that time between one month and four months out is pretty tricky.

Q: What other aspects were unexpected?

A: What to do about the anniversary, the one-year memorial. I knew we had to mark it, and I had some initial ideas on how we might mark it. And we brought it to the residents, all these “clever ideas,” and, gosh, they didn't like them. They had ideas that they thought would work better for them. But having those discussions raised a lot of complicated issues. If someone said, “Well, we should have an annual memorial lecture series,” then the question was, for how many years? Six years down the road, when people don't remember the deceased and staff has turned over, a memorial lecture may no longer have the same meaning for the people involved. How do you stop an annual event?

Some people suggested that we have a plaque, and other people thought, “I don't actually want to see the plaque on my way to call or my way to see the next patient.” Or, “I don't want prospective applicants to inquire about this plaque and keep highlighting the fact that we had a tragic loss.” So thinking about the anniversary and having really open discussions is really important.

Q: The framework in the paper takes into account many practical issues, such as working with the hospital communications staff, revising the call schedule, and informing affected patients. How do you determine who handles each of these responsibilities? Should there be one point person who assigns tasks?

A: Some hospitals have a very strong GME office, some departments have a very strong integrated chair, and other hospitals have really good EAPs [employee assistance programs], but it's very institution-specific: At a particular site, who's really good at getting something done, fast, and effectively?

Q: What kind of self-care is needed for faculty?

A: I think one of the first things I say [in the paper] is to call home. When I submitted the paper, a reviewer questioned that recommendation and said that whoever's leading the effort really has to just focus. I pushed back on the reviewer because I do think people need the people who support us to be engaged early. People do need support from the home front. And I don't think we can be effective if we don't know that people have our backs and are behind us.

I'm built to do well in a crisis, but not all leaders are. Their strengths are elsewhere—they're amazing grant writers or they're amazing teachers or surgeons or whatever their thing is—and so they may need even more support. I do think that people attending to their own mental health and well-being throughout is critically important. It's fundamental.

Q: If a program is developing their own framework for crises, what would you recommend as the first step?

A: It's really important to build a small community of people for mutual support. Probably the most important thing to do is to have a group that is mutually respectful, where things can be safely said with a lot of psychological safety. When these things arise, that group is ready to go. They've already worked together, they already know how to communicate, and they've got each other's backs.

Creating small leadership teams or small communities is important so that the group is together when [any kind of] tragedy strikes. And maybe that would be the department chair and the training director and the GME director, but maybe it isn't. Maybe it's the program coordinator and the secretary down the hall. It doesn't necessarily matter who's in there, but building those communities is pretty key.

Time pressures people face now make that work and putting in that investment harder and harder to pull off. But that's what really is needed, I think, to manage one of these sad situations successfully.