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With suicide the second-leading cause of death among medical students, it is not rare that those future physicians, along with school faculty and administrators, are forced to confront and cope with the shock of a student who takes his or her own life.
The panoply of reactions and coping strategies that students and medical school officials displayed in the face of one such tragedy at the Medical College of Georgia was vividly-sometimes poignantly-described by students, psychiatry residents, and a faculty member in an APA annual meeting workshop in Toronto in June.
"Brad" was nearing the end of his first year of medical school. Few people were aware of his history of depression, for which he had been treated, and of his recent increase in alcohol consumption. He had purchased a gun, an event about which he told no one. One Saturday evening he walked into woods not far from the school and fatally shot himself.
Cheryl Anderson is a third-year medical student and was a classmate of Brad's, though as an older student she spent more time off campus than many of her colleagues and did not know him well. On Sunday she learned of his death from another student who asked whether Anderson would call a list of students to inform them of Brad's suicide. A few of his classmates thought it important to inform personally as many students as they could reach, and she agreed to help in this task.
Unsure exactly how to react or deal with their shock and grief, some students who knew Brad well met that evening at the home of fellow student John Tieder, who was also on the annual meeting panel. The gathering had no articulated purpose but seemed to fulfill a need by students closest to Brad to share and process the tragedy.
Still other students did not learn about the suicide until Monday morning when they showed up for what they thought would be a long-scheduled test. Instead they were confronted by school officials who informed them of the death and a few facts in what Anderson described as "an administrative, businesslike way." One official, trying to reassure students, informed them, for example, that there was no indication that Brad had killed himself because of factors related to academic performance.
Anderson said she was distressed by the emotionless tenor of the presentation, in which little information about the funeral-which was expected to be a long distance from the school-was presented, and no offer made of an alternative for students who couldn't go to the funeral to express their grief. The main point of the gathering seemed to be to announce that exams and classes would be cancelled that day.
It is obvious that friends will grieve, and such a reaction will of course be deemed appropriate, she noted. But a lot of other students who were not close to the victim may be grieving "invisibly," partly in response to earlier events in their own lives, and need a forum for expressing their grief.
"Don't forget to pay attention to these students or act as if nothing has happened," she urged school officials. "They need to get together and hold each other just as close friends" of a suicide victim do. A suicide, whether of a classmate or patient, "is not something you just get over."
The classmate who may have had the most difficult time coping with Brad's suicide is Tieder, who was a close friend since the two were undergraduates. In fact Brad had told him that he was having suicidal thoughts but that he was getting help for his distress.
It fell to Tieder to inform Brad's girlfriend, psychiatrist, and others about the death. Adding to the emotions overwhelming him at this point, Tieder said, was another student who came to him on learning of Brad's suicide and revealed that he, too, had made a suicide attempt not long before. Not knowing the best way to respond to this disclosure, Tieder passed on this information to faculty member Donald Misch, M.D., director of education in the medical school's department of psychiatry and health behavior.
As did Anderson, Tieder, too, came away from the all-student meeting quite disappointed in the way the deans had conducted the session.
"I sensed that the deans were just trying to wash their hands of the whole issue" and return to business as usual, he said. Their colleague Jennifer Prichard related how valuable the informal get-together at Tieder's house was for those trying to sort through their emotions.
"There was lots of crying and hugging," she said. "Things that needed to be done." The Monday morning assembly, however, "was very much an institutional response, which was a shame because many students who needed a more relevant outlet [for their emotions] missed out on that opportunity," especially those who could not attend the distant funeral, she said.
Prichard, also a friend of Brad's, described what she called her "textbook" responses to his suicide. She proceeded through shock, denial, and, surprisingly, she observed, anger at Brad, the girlfriend who broke up with him the preceding month, and at his close friends-herself included-for not sensing his distress and intervening to prevent the outcome. Looking back now that more than a year has passed since the suicide, however, Prichard said that she could not identify any signals suggesting that Brad was contemplating suicide or points at which she could have intervened to prevent his suicide.
Coincidentally, two or three weeks after Brad's death, Misch was scheduled to teach a class on depression and suicide. He explained at the workshop that he had taken that opportunity to refer to Brad, careful to refer only to related events that were "in the public domain." Reactions were varied, he pointed out. Some students were grateful for the chance to discuss the issues with a psychiatrist; others were angry that he used Brad's death in this manner. The students on the panel indicated that they reacted positively to Misch's discussion.
Tieder stressed that the experiences surrounding the tragedy had "a powerful impact" on him. Among the ways it changed him was to alter radically his perception of the field of psychiatry. Where he was previously "extremely skeptical" of its role and efficacy, he developed considerable respect for the specialty, he emphasized.