Preventing Clinician Suicide: A Call to Action During the COVID-19 Pandemic and Beyond.

In this commentary, the authors offer a call to action in the long-standing fight to prevent clinicians from dying by suicide. In April 2020, the nation was shocked by the suicide of New York City emergency physician Dr. Lorna Breen, who died while recovering from COVID-19. She joins an unknown number of clinicians who have taken their lives over the past year. The authors introduce Dr. Breen, a highly talented physician working on the frontlines of the COVID-19 pandemic, and examine how pervasive distress and suicide are in clinicians. Then, they explain the lived experience movement and highlight how clinicians speaking openly about their mental illness and treatment are making it easier for their colleagues to seek lifesaving help, despite the stigma still surrounding mental illness and treatment in medicine. The authors sort through the science of clinician distress; critique how the COVID-19 pandemic is affecting the lives of clinicians; and describe existing national initiatives to address clinician stress, burnout, and suicide. Finally, they recommend evidence-based actions to prevent clinician suicide that multiple stakeholder groups can take, including regulatory agencies, licensing boards, and hospital privileging boards; specialty boards, professional associations, and continuing education organizations; medical educators; and individual clinicians. Suicide is a complex but generally preventable cause of death. Those in medicine must forge ahead with collective momentum. Dr. Breen, so many other clinicians, and those they have left behind deserve nothing less.

Support Groups and Individual Mental Health Care via Video Conferencing for Frontline Clinicians During the COVID-19 Pandemic.

BACKGROUND: The current coronavirus disease 2019 (COVID-19) pandemic has put an enormous stress on the mental health of frontline health care workers. OBJECTIVE: Psychiatry departments in medical centers need to develop support systems to help our colleagues cope with this stress. METHODS: We developed recurring peer support groups via videoconferencing and telephone for physicians, resident physicians, and nursing staff, focusing on issues and emotions related to their frontline clinical work with COVID patients in our medical center which was designated as a COVID-only hospital by the state. These groups are led by attending psychiatrists and psychiatry residents. In addition, we also deployed a system of telehealth individual counseling by attending psychiatrists. RESULTS: Anxiety was high in the beginning of our weekly groups, dealing with fear of contracting COVID or spreading COVID to family members and the stress of social distancing. Later, the focus was also on the impairment of the traditional clinician-patient relationship by the characteristics of this disease and the associated moral challenges and trauma. Clinicians were helped to cope with these issues through group processes such as ventilation of feelings, peer support, consensual validation, peer-learning, and interventions by group facilitators. People with severe anxiety or desiring confidentiality were helped through individual interventions. CONCLUSIONS: Our experience suggests that this method of offering telehealth peer support groups and individual counseling is a useful model for other centers to adapt to emotionally support frontline clinical workers in this ongoing worldwide crisis.

The Mentally Ill Physician: Issues in Assessment, Treatment and Advocacy.

This position paper has been substantially revised in collaboration with the Canadian Psychiatric Association's Professional Standards and Practice Committee and approved for republication by the CPA's Board of Directors on April 8, 2019. The original position paper, 1 now an historical document, was first approved by the Board of Directors on October 4, 1996.

Medical Licensure Questions About Mental Illness and Compliance with the Americans With Disabilities Act.

Substantial numbers of medical students and physicians live with some form of mental illness. Over the years, many medical licensure boards have asked physician medical licensure applicants with Doctor of Medicine (MD) degrees intrusive questions about whether they have any psychiatric history. This has discouraged many who need psychiatric treatment from seeking it because of fear of the questions. Gradually, court decisions and the United States Department of Justice have established that such questions violate the Americans with Disabilities Act (ADA). The 2014 Louisiana Supreme Court Settlement Agreement set definite limits on law licensure mental health questions, followed by a least one licensing body revising its physician licensure questions to be consistent with ADA standards. In this article we examine the current medical licensure questions from each state and the District of Columbia about the mental health of applicants and discuss their validity under ADA standards. Our original investigation of these questions found that the majority still ask questions that are unlikely to meet ADA standards. The judicial and Department of Justice developments, however, may compel them to abandon these questions. If not, legal action will enforce ADA compliance. This change will significantly benefit applicants who need psychiatric treatment.

Direct Supervision in Outpatient Psychiatric Graduate Medical Education.

OBJECTIVE: The authors describe a stimulus case that led training staff to examine and revise the supervision policy of the adult and child and adolescent psychiatry clinics. To inform the revisions, the authors reviewed the literature and national policies. METHODS: The authors conducted a literature review in PubMed using the following criteria: Supervision, Residents, Training, Direct, and Indirect and a supplemental review in Academic Psychiatry. The authors reviewed institutional and Accreditation Council for Graduate Medical Education resident and fellow supervision policies to develop an outpatient and fellow supervision policy. RESULTS: Research is limited in psychiatry with three experimental articles demonstrating positive impact of direct supervision and several suggesting different techniques for direct supervision. In other areas of medicine, direct supervision is associated with improved educational and patient outcomes. The authors present details of our new supervision policy including triggers for direct supervision. CONCLUSIONS: The term direct supervision is relatively new in psychiatry and medical education. There is little published on the extent of implementation of direct supervision and on its impact on the educational experience of psychiatry trainees and other medical specialties. Direct supervision has been associated with improved educational and patient outcomes in nonpsychiatric fields of medicine. More research is needed on the implementation of, indications for, and effects of direct supervision on trainee education and on patient outcomes.

Current state of psychotherapy training: preparing for the future.

This article provides an overview of what is currently being taught in psychiatry residency programs about psychotherapy in general, and to evolving changes in the field related to mental health parity and the Affordable Care Act (ACA) in particular. Future psychiatrists must have a firm grasp of not only the principles of psychotherapy but also the development of increasingly effective and evidence-based psychotherapies if they are to be effective health care leaders. We review what attracts medical students to psychiatry and how much their decision to train in psychiatry is rooted in a desire to learn both dynamic psychiatry and psychotherapy in its various modalities. It is no secret that the quality of teaching and learning psychotherapy is variable in our training programs. One reason for this can be attributed to trainees who ascribe more to the biological dimensions of our field and have less interest and commitment to more than basic skills in psychotherapy. In addition, in some settings there is a dearth of teachers trained in the various forms of psychotherapy who are committed to this pedagogical imperative. We conclude with several recommendations to residency training programs and to residents themselves regarding what we deem essential in both the curricular and clinical exposure to the challenges and shortcomings of the mental health parity and Affordable Care Act. Tomorrow's psychiatrists have a fiduciary responsibility of advocating for their complex and chronically ill patients that must include providing psychotherapy.

Ethical dilemmas in clerkship rotations.

A sound clinical education should include the opportunity for medical students to engage in a spirited and informed discussion with faculty about the ethical challenges they will undoubtedly face. Unfortunately, in many medical schools today this goal is thwarted by many factors, including denial that a problem exists, relentless system overload, unprofessional behavior, breakdown in communication, and inertia. What is worse is that this problem is not new, and the fallout is not insignificant. Another potential contributing factor is burnout, which is well documented in a high percentage of medical students, residents, and faculty, and two of its most serious consequences are patient dissatisfaction and medical error.The authors draw on hundreds of student reflections on ethical dilemmas submitted during classroom exercises to examine persistent themes. They posit that classroom and didactic teaching is not enough to enable students to face ethical dilemmas. The authors call for a major culture change in medical education: "buy in" from top administration, especially the dean (and associate/assistant deans), chairs of all departments, and clerkship and residency training directors; the appointing of an ombudsperson and/or ethicist to oversee and resolve issues as they arise; instructional workshops and materials to enhance and impart skills for all teachers; remediation or retiring of errant faculty; and ongoing research and dialogue between and among medical centers about novel solutions.

Physician impairment: is it relevant to academic psychiatry?

OBJECTIVE: This article examines the relevance of physician impairment to the discipline of academic psychiatry. METHOD: The author reviews the scientific literature, the proceedings of previous International Conferences on Physician Health, and held discussions with experts in the physician health movement, department chairs, program directors, and residents. RESULTS: Psychiatric illness and impairment in physicians impact academic psychiatry in several ways. Mental illnesses in physicians are being studied by some researchers, but the subject requires more scholarly attention. Training directors are interested in resident well-being and illness and how to reach out to symptomatic residents in a more timely way. Leaders in psychiatry are eager to learn the first steps in identifying colleagues at risk and the route to assessment and care. They are especially concerned about disruptive behavior in the workplace, including harassment and boundary transgressions in doctor-patient and supervisor-supervisee relationships. Academic psychiatrists wish to be more responsive to nonpsychiatrists appealing to them for guidance with impaired members of their departments. CONCLUSIONS: Physician impairment is an emerging field of study and interest to psychiatrists in academic settings.

Touched by suicide: bridging the perspectives of survivors and clinicians.

This article is a revised version of an invited plenary address given at the 39th Annual Conference of the American Association of Suicidology. The authors, a psychiatrist and a writer survivor, outline and summarize the different ways in which professionals and survivors come to an understanding of suicide. They explain how each group often exists independently and separate from the other--by cognitive and emotional dissonance, by private language, by psychological defenses and miscommunication--and call for dialog. They argue that both perspectives are essential to advance the science of suicidology and to give hope and meaning to those bereaved by suicide.

Medical marriages and other intimate relationships.

Marital challenges are ubiquitous in the relationships of doctors. Common issues include overwork, a need for control, self-neglect, perceived and felt stigma, being a "wounded healer", trouble with boundaries, chemical dependency, depression, and more. Knowing the hallmarks of a healthy relationship, recognising warning signals of trouble, and taking action through suggested strategies can be salutary.