Academic paper Title“Dealing with Suicidal Patients – a Challenging Task: A Qualitative Study of Young Physicians’ Experiences.” This study offers insight into health professionals’ (HCP) perspectives and experiences working with suicidal patients.
 The findings highlight factors which should be addressed in physician training to enhance HCPs’ wellbeing and their quality of work with suicidal patients.
Høifødt, Tordis Sørensen, and Anne-Grethe Talseth. “Dealing with Suicidal Patients – a Challenging Task: A Qualitative Study of Young Physicians’ Experiences.” BMC Medical Education 6, no. 1 (2006). https://doi.org/10.1186/1472-6920-6-44.
Synopsis of paper  To shed light on the meaning of newly educated physicians’ lived experiences in treating patients at risk of committing suicide. Result section organised as: Three main themes and ten themes were noted:

Striving for relatedness:
A. Relating with the patient
B. Not being able to relate with the patient

Intervening competently:
A. Having adequate professional knowledge
B. Performing professionally
C. Having professional values
D. Evaluating one’s own competence

Being emotionally involved:
A. Accepting one’s own vulnerability
B. Feeling morally indignant
C. Feeling powerless
D. Accepting one’s own fallibility
Prominent experiences identified  Theme 1. Striving for relatedness:

A. Relating with the patient Wishes to establish positive relationship with patient Interested in understanding patient’s problem and reason for suicide ideationWhen they understanding patients better, more inclined to trust what they say 
B. Failed relation to patient Sensed that patients avoided certain topic, yet unable to establish emotional connection
Struggled to see suicidal ideation as authentic or as means to get attention Previously experienced being manipulated by patient, often as means to get addictive medication   

“He had used addicting medication. He was appealing to get them, it was obvious that he did not want to kill himself, but he wanted other things.”   “I tried to see if I could get through to him some way… We talked a little about school, what he had done the last days, but I could not find an opening. When I asked whether he had some problems, he would not go into them.”

Theme 2. Intervening competently:
A. Possessing adequate professional knowledge
Physicians prioritised history taking, giving patient space to speak about their future and extent of impulsive/unusual behaviour
Also noted specific signs regarding clothing, hygiene, smell, self-harm, emotional lability
Crafted hypotheses on diagnosis

B. Professional performance
Expectations of family and colleagues on physicians to change patient’s mindPreparing resources as needed  

C. Upholding professional values
Heavy responsibility to save the patient
Decision to admit patient to hospital often brings moral distress  

“I did not feel bad in making the decision [to admit the patient], but I felt uncomfortable watching the reactions of the patient… I have gone over it again and again, is the decision justifiable, have I tried out everything else possible?”  

D. Evaluating own competence
Fearful of consequences of wrong judgement call  

“Did I do something wrong – that was the immediate reaction – am I going to be charged? The consequences: I was afraid of the consequences; maybe I have made an error, made the wrong assessment.”  

Theme 3. Emotionally involved:  
A. Acknowledgement of their own vulnerability
Patient’s suicidal ideation stirs discomfort and anxiety in physicians  

“One gets scared of the forces expressed in “I want to commit suicide”. You are supposed to be professional, on the other hand, one also has personal feelings, which patients like these, really can stir. One might get upset, feel pain and fear.”  

Reactivation of their own past ideations/experiences of suicide
Grief and guilt of making wrong decision after patient succeeds in committing suicide  

B. Moral indignation
Aggression and annoyance towards patients  

“When people [commit suicide], I get angry; I try to keep that to myself, because it is not very useful in the relationship with the patient. You get angry with a person because he just drives into an oncoming trailer. He didn’t really have huge problems. His action was indefensible.”  

C. Powerlessness Helpless and tired  


“It just gets to be too many of them, you get so tired. “The intoxes” with those pills are often people that come again and again… It sounds awful, but I sometimes thought, if they really want to kill themselves, why don’t they take a large enough dose [to do the job].”  

“How good are we at picking up those who are really at risk to commit suicide? There is no guarantee that a patient will survive to the next day even if he has been to the doctor.”
What do these prominent experiences mean?   Theme 1. Striving for relatedness: Communication & establishing contact was recognised as an essential aspect in preventing suicide.Communication includes both professional knowledge and empathy. Taking into account interplay of feelings, rationality and ethical considerations, patient’s history, the present situation and a perspective for the future   Communication in the case of: A. Mutual trust between physician and patient…
– There was an understanding of the patient, the physician felt comfortable in making assessments and treatment plans.  B. Lack of relatedness
– The physicians experienced difficulties with feelings of helplessness, insecurity and/or anger.  C. If the patient showed signs of serious mental illness
– The physician’s path forward was clearer and easier to deal with.

Theme 2. Intervening competently:
Physicians discussed competence as having adequate knowledge, their performance, values and consequences of their work.   Competence was marked by:

A. A thorough assessment of the suicidal patient.
Empathy is highlighted as the physician tries to understand the suicidal patient’s view of their life: past, present and futures

B. Having a patient plan and following protocol,
was valued as competent work and eased the physicians Personal toll of professional work on the physicians

A. Ethical dilemma
Physicians felt they had to compromise on their values to competently work, for example admitting a patient against their will. Some physicians saw this as a breach of the patient’s autonomy (an ethical dilemma).

B. The pressure to save a life made physicians sensitive to critique and fearful of the consequences of their work. E.g., a faulty decision. Physicians had a fear of losing their professional appearance and control.

Theme 3. Being emotionally involved
Physicians described feelings of vulnerability, powerlessness and the stress of uncertainty a patient may commit suicide.  

Physicians felt anxiety and pain when dealing with suicidal patients

Navigating professional work & personal feelings
How the physicians should approach suicide as a professional and their personal feelings attached to the patient’s outcome were difficult to navigate.

Physicians felt at fault when a patient committed suicide, worrying themselves about what they did wrong/ not enough of

Symptoms of burnout:
Physicians expressed a strong opinion e.g. felt annoyance/ anger at patients’ reckless behaviour
Physicians felt powerless: helpless and tired watching their patient make several suicide attempts

Preparation for the worse outcome (patient suicides): Physicians knew they had to live with the uncertainty their patient may suicide. As a result, they reflected over their reaction to prepare themselves for the worse outcome
Key messages for HCP:  HCP to patients/patients’ NOK: Do not suffer alone.
There is help and support out there. It may feel scary, however seeking professional help is an essential step forwards towards support & prevention.

HCP to other HCP The current study revealed young physicians experienced ethical dilemmas, and challenging emotions when working with suicidal patients. HCPs should provide additional support for young HCPs.
Such as: 
A. Providing supervision
Senior/ more experienced HCPs could supervise young HCPs. Provide them room for reflection, discussion and professional advice.
B. Education of physicians
Clinical teaching addressing suicide specifically is needed to prepare new HCPs and prevent burnout.

HCP to themselves:
Recognising burnout symptoms
According to the current study symptoms of burnout were apparent in young physicians. Being aware of these symptoms are crucial for addressing self-care and maintaining quality work.

Burnout symptoms when working with suicidal patients (apparent in the present study) include:
Loss of motivation
Feeling helpless, trapped or defeated
Detachment
Increased cynical or negative outlook
Decreased satisfaction or sense of accomplishment  

Other general symptoms include:
Feeling tired and drained most of the time
Lowered immunityFrequent headaches and muscle aches
Change in appetite or sleep habits
Withdrawal from responsibilities
Isolating from others
Procrastinating  

Boundary setting
It is apparent in this study that HCPs developed strong personal opinions of their suicidal patients. And felt responsible for the patients’ outcome.
It is important to practice boundary setting to: Not let personal judgements influence your professional approach
Accept the uncertainty of the patient’s outcome and the limits of your control over the outcome.  

Sources:
1. “Avoiding Physician Burnout: Symptoms & How To Address It”. 2021. Teamhealth. https://www.teamhealth.com/news-and-resources/white-paper/avoiding-physician-burnout/?r=1.

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