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This blog forms part of the BMA Cymru Wales International Stress Awareness Day Series
The author has chosen to remain anonymous to protect the identity of the patient
A few weeks into my first training post in psychiatry, I saw a patient who went home to kill themselves. I had seen them on two occasions but they seemed more unwell the second (and last) time I saw them. The patient denied any suicidal ideation but seemed increasingly paranoid. I discussed the case with the on-call registrar, we came up with a plan, discharged the patient home with a prescription for a low-dose antipsychotic and a referral to the home treatment team. The patient committed suicide hours after leaving A&E.
My consultant accidentally broke the news to me about the patient’s suicide on the phone a few days later (I had been off after a week of night shifts) assuming that I already knew. I felt a mixture of shock and terror that I had missed something or done the wrong thing. Grief would belong to the patient’s family rather than me.
A serious and untoward incident inquiry would happen (a standard procedure). A manager said off-handedly that my “questionable” decisions would be reviewed there. The inquiry concluded that there was nothing more that I, nor the on-call registrar, could have done.
Objectively, I knew I had done everything I could. I had assessed the patient’s risk and acted according to what the patient told me and how they behaved but I still felt that I had let the patient down or had been negligent in some way. I’d even been told that my decision was questionable so it must have been true! My ward manager arranged for me to see a psychologist to debrief; they helpfully suggested that the way things are dealt with can be worse than the incident itself but I kept revisiting the manager’s flippant remark. My worries over my “questionable” decision grew until it defined me. I was no longer objective and I clung on to negative thoughts and dismissed any positive ones.
I felt a need to exert control over everything. I couldn’t dictate clinic letters in case I put in a glib comment that a patient would misinterpret. I typed all my own letters and discharge summaries and worried about choosing the right words to say to patients. The need to have control exaggerated my workload and caused me worsening anxiety, but I couldn’t see this at the time. Obsessive and compulsive behaviours spiralled and spilled over into my personal life. I couldn’t do anything without being paralysed by fear that I had done something wrong or that I would be judged. I worried that I was a terrible doctor, that something had gone wrong and that I had mistakenly been allowed to graduate. Someone would catch up with me soon and tell me it was a mistake so I had to be absolutely perfect all the time. Any mistake would mean that I was an incompetent doctor, I would end up in front of the GMC, be struck off, I wouldn’t have a job…
I almost quit my job because of the extreme anxiety I was experiencing and I would have done if I hadn’t been referred to a service run by psychiatrists for doctors experiencing psychological problems. Looking back, I can’t believe that the stress of a patient’s suicide and its aftermath trapped me in a cycle of believing negative thoughts which almost destroyed my career. Two courses of cognitive behavioural therapy helped me regain objectivity, my sanity and my career.
Ten years on, I completely understand that there was nothing else that we could have done, that I had done nothing wrong and that people use words without thinking about how they impact on others. My practice had, in fact, been exemplary. High expectations and a pursuit of perfection mean that doctors are our own worst enemies, so when we fall, we can fall hard. I would suggest to anyone going through anything similar to seek help early; yielding to being someone else’s patient is not giving in, it’s at the very least good medical practice.
Thanks for sharing. Good insight into an at-the-time paralysing lack of insight
Thank you for sharing this.
Hear hear we must all be patients in order to know what it is like despite it being hard to be one vulnerable and exposed
This has just happened to me and I resonate with some of what you're saying. Don't yet know what the next steps are and like you I've been on leave immediately following the event. I wish there was some standardised support for this, or even just information about what's likely to happen next. My consultant seemed more shaken up than I was so I don't really feel comfortable burdening them. I'm nervous that I may end up in the coroner's court and I'm unsure whether they'll find fault with my practice (although on the face of it I think we did what would reasonably be expected). I really hope things don't spiral in my head like they did for the author of this thread; I don't want to suffer anxiety and a crisis of confidence...