On the Death of House Officers

[On receiving Lawrence Smith's account of the death of a resident, we invited other medical educators to reflect on such events. Drs. Fitzgerald and Murray wrote the following separate perspectives in response. -The Editor]

Dr. Fitzgerald: In the second month of his internship, having for half that time been at home on medical leave under therapy for depression, my intern Jeff cut his throat from ear to ear.

I had not known him well. At the welcoming party for new housestaff in my backyard, he appeared cheerful and interactive. Three weeks later, a perceptive chief resident brought Jeff to my office, where he told me of the debilitating depression he had had in college, its current and insidious return, and his incapacitation by it. Two weeks later I spoke to him again; now on leave and with the help of his therapist and brother, he felt better. He asked about resuming his internship, and I assured him that the place was his when he and his physician thought he was ready for it. Two weeks after that he was dead.

How had I not seen an anguish so great that the violence he did against himself was the lesser torment? Of course, I blamed myself, and was blamed-as program director-by both his family and his medical school classmates. All assumed that it was the stress of internship that precipitated his suicide. Intellectually, in retrospect, it seems unlikely; on an emotional level, however, one is compelled to look for an external event with an impact sufficient to explain the magnitude of the horror that was done. The inexplicable is too terrible, too fearful: A reason must be found.

Because we knew him so short a time, the response to his death among the housestaff was more shock than grief. He really had not had an opportunity to make friends among his peers in the intern group. They quickly forgot him, but I never have. I reviewed his application file, looking for those understated or code-hidden indications of depression (unexplained absences from medical school, allusions to mood). There were none. Either his medical school days were free of despair or he kept it extremely well hidden. Another possibility was that his medical school mentors were less than forthcoming. What I did find in his record was that he had been a clever, kind, and giving man, possessed of a radiant, gentle sweetness. His interpersonal relationships with patients had been particularly noted-he seemed to express a peculiarly receptive empathy. Perhaps this was an indication of his personal knowledge of the agony of hopelessness. He would, I think, have been a magnificent physician, and I mourned the loss of the man who might have been.

Certainly we had done everything “by the book.” The program was supportive, got him into therapy quickly, allowed him the time necessary-without recrimination or intimation of perceived weakness-to regroup. We assured him of his position when he was ready to return. The one thing that may have gone wrong is that he had asked me whether he could switch to a housestaff position in a nearby city; I had told him that I would do everything I could but could not guarantee him a position in another program. After his death, his parents lashed out at me, asking that I be fired, because I had told him that “he could not get an internship again.” In retrospect, I do not think I could have lied to him, but perhaps I could have told him that particular truth in a different way, of my lack of power to help him.

He haunts me still. With each new class of interns, I wonder “Will there be another?” I scrutinize the applications, look carefully at faces, body language, volubility, and mood at first meeting. I tell the housestaff that we in the department are wed to the furtherance of their best interests and that should they have any difficulty they should come to us right away. The terrible thing is that none of these things would have made a difference for Jeff.

I have had depressed housestaff before and certainly since. The powerful grip of that malignant disease, which robs a person even of his or her ability to fight it because it strikes so near the core, has never seemed trivial to me. In medical students and house officers, it may be more often linked to intensity of purpose and compulsive behavior (for which we select in medical students) than in the general population, but I do not know this to be a fact. It is, I think, too facile to attribute depression to external circumstance, and I believe that depression is an internal phenomenon, biochemically based. We grope for external explanations, constructing reasons in the language of daily experience largely to satisfy our own needs for sense and control. Would modification of external experience make a difference? Would it simply change the explanations given for such awful tragedies? I don't know. I just don't know.

Dr. Murray: It was in my first few weeks as dean of the medical school that I got a call saying that one of my students had committed suicide. She closed the garage door one summer afternoon and turned on the car engine. I was stunned and confused and saddened. She was one of our more promising students. I had supervised her elective project the previous year and had seen no warning signs.

Some months earlier, I had told the dean's selection committee that one of the changes I wanted to see was the incorporation of humanistic values and the humanities into the life of medical students. Our hope was to change the atmosphere and culture of medical school, reducing the deadening and sometimes brutalizing aspects of our training that we all remember. The byword was, “If you want humane physicians, start with a humane medical school.” Our resolve and our principles were now to be tested.

Traditionally, medical students learn from their first sight of the cadaver in the anatomy laboratory to remain calm and unemotional. They are told: “Don't be a wimp. You're training to be a doctor, and doctors have to deal with all sorts of bad and sad stuff every day. You can't get emotionally involved.” Everybody knows that. Stiff upper lip, a nod to the unfortunate and sad event, but onward and upward. Remember Osler's aequenimitas. These were the sentiments when I was in medical school.

That was then, this is now. The director of our Student Advisory Service suggested that we immediately call all of the classmates and friends who were around during the summer and then contact the other classmates. A class is like a family and needs to be together at a time like this.

The next night we met at the student advisor's home. There were lots of hugs and tears as the students arrived. As one student said later, it was a night of “pizza and tears, confession and beers.”

They began to talk, about their classmate and about how they felt. The talk later shifted to other experiences: the death of a parent, a friend in a car crash, a neighbor with AIDS, interviewing a patient with cancer. It was the first time many had had a chance to talk about events that continued to trouble and confuse them. They talked about how they were going to deal with the sadness, disappointments, and personal losses that accompany the rewarding experiences of medical practice. They were learning important lessons. So was I.

They met many times after that initial meeting and again when the remaining classmates returned. Later that year, all took part in the presentation of a painting in their dead classmate's honor for the medical school, a painting of a moonlit evening over the Atlantic and a great gray heron flying with the clouds. Only time will tell, but we felt that maybe, just maybe, we were getting a start on a humane medical school.

Dr. Murray: Clinical Research Center, Dalhousie University, 5849 University Avenue, Halifax, Nova Scotia B3H 4H7, Canada.

• Copyright ©2004 by the American College of Physicians