Abstract
Purpose:
Youth suicide is a public health emergency and its prevention is a national imperative. Pediatric providers are critical to risk assessment, triage, and intervention, yet little is known about the content, quality, and perceived adequacy of suicide prevention pediatric residency training. We thus sought to: (1) characterize suicide risk assessment and management training practices in pediatric residency programs nationwide, and (2) assess areas of training need to guide curricular development.
Methods:
An online nationwide needs assessment was distributed to all 204 pediatric residency program directors (PDs) and 494 pediatric chief residents (CRs) through the Association of Pediatric Program Directors listservs (May-June 2017). Descriptive statistics and comparisons between PDs and CRs are reported.
Results:
Ninety-five PDs and 210 CRs (47% and 43% response rate, respectively) completed the survey. Although 82% of respondents rated suicide prevention training in residency as “very” or “extremely” important, a minority (18% PDs, 10% CRs) reported adequate preparation relative to need. Formal training was not universal (66% PDs, 45% CRs) and practices varied across programs (PD median=3 hours [IQR:1-4.5 hours], CR median=1.5 hours [IQR:0-3 hours]). Top-ranked educational priorities included interviewing adolescents about risk, risk factor identification, and locating community resources. Training barriers included limited time, lack of training resources, and need for additional expert faculty to guide training.
Conclusions:
PDs and CRs reported constraints to suicide prevention training for pediatric residents despite high perceived importance and need. Programs may benefit from explicit guidelines and standardized curricula that emphasize educational priorities, building on these findings.
Keywords: Graduate medical education, suicide prevention training, adolescent health, needs assessment
Suicide is a complex, but preventable public health problem. Within the U.S., suicide represents the second leading cause of death among adolescents and young adults.1 Despite growing suicide prevention efforts,2,3 suicide rates have not markedly declined, and instead have increased.1 Youth suicide-related hospitalizations have also increased,4 and in 2015, the suicide rate among girls aged 15-19 was the highest observed in 40 years.1 These findings underscore the importance of suicide prevention efforts among youth.
Importantly, the majority of individuals who die by suicide visit their healthcare provider in the weeks prior to death,5 and the majority of youth who attempt suicide confide in a trusted adult prior to their attempt.6 These data suggest a missed detection of suicide risk by providers and highlight a crucial intervention opportunity. Among youth specifically, pediatricians may serve as a critical point of contact for suicide risk screening, triage, and intervention. Although physician education has been shown to be an effective suicide prevention strategy,7,8 little is known about actual suicide prevention training in U.S. pediatric residency programs.
To offer guidance to pediatricians on suicide prevention, the American Academy of Pediatrics (AAP) released a 2016 policy statement9 that included recommendations to consistently screen adolescents for suicide risk. Additionally, the Accreditation Council for Graduate Medical Education (ACGME) requires that education on internalizing behaviors, such as suicide risk, be included in the Developmental-Behavioral Pediatrics rotation.10 It is unknown, however, the degree to which these standards have influenced resident education. Indeed, the most recent study of suicide training in pediatric residency programs was conducted over a decade ago in 2007. The study found, at that time, less than half of pediatric program directors rated their program’s suicide prevention training as adequate.11 Specific areas where training was desired were not studied and residents’ perspectives not sought.
Other studies have found pediatricians report a lack of training in suicide risk assessment as a barrier to patient screening.12 Inadequate training in this area may be further compounded by variable clinical practice guidelines (CPGs) for suicide risk assessment and management across multidisciplinary fields.13 Last, although use of screening instruments aids risk detection14 and brief psychosocial interventions show efficacy in reducing suicide risk,15 little is known about their use in pediatric residency training. Taken together, research is warranted to further evaluate current suicide prevention training practices in pediatric resident education, including opportunities for improvement.
We conducted a nationwide needs assessment survey of pediatric program directors (PDs) and chief residents (CRs) to investigate: (1) the nature of current suicide risk assessment and management training practices among pediatric residency programs, and (2) perceived areas of training need to guide curricular development for pediatric residents. Extending previous research, we collected responses from both PDs and CRs, using CRs as a proxy for residents, in an effort to identify possible differences between PDs’ and residents’ perceptions of training delivered and additional training desired. Ultimately, by improving suicide risk assessment and management training among pediatric residents, pediatric suicide prevention efforts more broadly might be enhanced.
Methods
Study design
We conducted a cross-sectional descriptive study to assess suicide risk assessment and management training practices and educational needs in pediatric residency programs nationwide. This study was approved by the Stanford University Institutional Review Board.
Survey design
We developed parallel PD and CR surveys based on literature review and in consultation with suicidologists and pediatric residency education experts. Twelve topics representing critical elements of suicide risk assessment and management (e.g., identifying risk factors) were identified but were not meant to be exhaustive (see Table 3).2,8,9,13,16 The final topic list was reviewed and approved by coauthors and subsequently by the Association of Pediatric Program Directors (APPD), the largest organization of pediatric residency directors accredited by the ACGME. As part of survey development, the questionnaire was piloted by one pediatric residency PD, two associate PDs, and three pediatric residents at Stanford University. Following survey submission to the APPD, additional peer-review and approval was conducted by a subset of the APPD Research and Scholarship Taskforce that consisted of three pediatric residency PDs. The survey was designed to take less than ten minutes to complete.
Table 3.
Program Director and Chief Resident Attitudes Towards Suicide Risk Assessment and Management Training
| Program Directors N (%) | Chief Residents N (%) | |
|---|---|---|
| Self-Rated Importance of Providing Formal Training to Residents on Suicide Risk Assessment and Management | ||
| Not at all important | 0 | 1 (0) |
| Slightly important | 3 (3) | 11 (5) |
| Moderately important | 14 (15) | 27 (13) |
| Very important | 38 (40) | 101 (49) |
| Extremely important | 40 (42) | 68 (33) |
| No response | 3 | 2 |
| Extent to Which Program Prepares Residents For Suicide Risk Assessment and Management | ||
| Not at all | 0 | 11 (5) |
| To a small extent | 35 (37) | 79 (38) |
| To a moderate extent | 43 (45) | 99 (47) |
| To a great extent | 16 (17) | 18 (9) |
| To a very great extent | 1 (1) | 3 (1) |
| No response | 0 | 0 |
| Perceived Importance of Topics For Resident Educationa | ||
| Identifying risk factors, warning signs, and protective factors | 87 (92) | 187 (89) |
| Interviewing pediatric patients about suicide using clear and direct language | 83 (87) | 183 (87) |
| Triaging patients based on risk | 80 (84) | 175 (83) |
| Administering standardized suicide risk assessments | 64 (67) | 156 (74) |
| Locating relevant community resources | 82 (86) | 176 (84) |
| Pharmacologic interventions in pediatric patients at risk of suicide | 39 (41) | 119 (57) |
| Psychosocial/behavioral interventions in pediatric patients at risk of suicide | 55 (58) | 166 (79) |
| Developing an individualized safety plan to manage risk on an outpatient basis | 74 (78) | 170 (81) |
| Educating families to assist in risk management | 74 (78) | 171 (81) |
| Coordinating care with clinicians in mental health services | 75 (79) | 179 (85) |
| Knowledge of legal and ethical aspects of suicide risk assessment and management | 53 (56) | 144 (69) |
| Postvention practices (i.e. best practices following patient death) | 54 (57) | 144 (69) |
| No response | 0 | 2 |
| Topics Where Resident Education Should Be Expandedb | ||
| Identifying risk factors, warning signs, and protective factors | 50 (53) | 108 (52) |
| Interviewing pediatric patients about suicide using clear and direct language | 58 (61) | 120 (58) |
| Triaging patients based on risk | 37 (39) | 83 (40) |
| Administering standardized suicide risk assessments | 30 (32) | 55 (26) |
| Locating relevant community resources | 51 (54) | 113 (55) |
| Pharmacologic interventions in pediatric patients at risk of suicide | 25 (26) | 88 (43) |
| Psychosocial/behavioral interventions in pediatric patients at risk of suicide | 38 (40) | 73 (35) |
| Developing an individualized safety plan to manage risk on an outpatient basis | 31 (33) | 98 (47) |
| Educating families to assist in risk management | 30 (32) | 68 (32) |
| Coordinating care with clinicians in mental health services | 46 (48) | 69 (33) |
| Knowledge of legal/ethical aspects of suicide risk assessment and management | 19 (20) | 43 (21) |
| Postvention practices (i.e. best practices following patient death) | 12 (13) | 41 (20) |
| No response | 0 | 3 |
| Desired Format for Curriculumb, c | ||
| Didactic Session(s) | 14 (15) | 62 (30) |
| Case-Based Group Discussion(s) | 59 (64) | 103 (50) |
| Online Module(s) | 33 (36) | 50 (24) |
| Independent Reading/Journal Article(s) | 1 (1) | 12 (6) |
| Website/Toolkit(s) with References | 21 (23) | 47 (23) |
| Evidence-Based Practice Guidelines(s) | 29 (32) | 77 (37) |
| Standardized Patient Exercise(s) | 15 (16) | 41 (20) |
| Directly Supervised Experience(s) | 11 (12) | 24 (12) |
| No response | 3 | 2 |
Importance included respondents’ selecting “very important” or “extremely important” for each content area.
Percentages do not add up to 100, as respondents were able to select more than one option.
To ease interpretation and comparisons for tabled results, the top two categories were collapsed for review.
The final survey (available as a supplementary file) included 24 questions addressing three core areas: (1) suicide risk assessment and management training practices, (2) attitudes and experiences related to suicide risk assessment and management training, including training priorities, perceived barriers, and areas for additional training related to the aforementioned 12 topics, and (3) residency program characteristics and participant demographics. Question formats included Likert-type scales and ranked-item ratings. One open-ended question asked participants to describe what role they believed pediatricians play in suicide risk assessment and management to solicit additional perspectives not captured through other questions.
Survey distribution
The final survey was hosted online via a secure web-based portal (Qualtrics, Provo, UT) for anonymous data collection and distributed via the APPD PD and CR email listservs. These listservs include all 204 PDs and 494 CRs of 204 total U.S. pediatric residency programs. Invitations to complete the survey were sent to APPD listserv members weekly by an APPD member for four weeks (May-June 2017). Informed consent was obtained prior to survey initiation and participants were offered a $10 gift-card upon completion through an anonymous link.
Statistical analysis
Descriptive statistics were calculated for all variables. For ranked variables, respondents’ top 2 most favorable selections were grouped. PD and CR selections of “very” and “extremely” important were combined for each content area as both responses indicated high importance and for ease of data interpretation.
Exploratory post hoc one-way ANOVAs were used to compare PD versus CR-rated importance of suicide education topics. Although PDs and CRs are not independent groups, we conducted analyses to evaluate agreement in topics that could direct curricular development. Post hoc chi-square and Mann-Whitney tests were employed to assess whether responses varied by program geographic region, type (university, community, military), or existence of an adolescent medicine fellowship. Significance levels were set at 0.05. Analyses were completed using SPSS Version 25 (Armonk, NY).
L.S. and A.B. manually coded all responses from the open-ended question to identify themes through summative content analysis.17 First, both authors independently inductively coded the data before meeting to agree upon one codebook. Then, the authors recoded all responses using the established codebook. Third, the authors met to discuss and resolve disagreements in coding until 100 percent consensus on all code applications was reached. Finally, the authors combined codes into themes. To ensure validity, all authors reviewed the final list of themes and associated quotations.
Results
Program characteristics
Ninety-five PDs (47%) and 210 CRs (43%) completed the survey. Not all respondents answered all questions; denominators other than 95 and 210 are noted (see Tables). The majority of PDs (83%) and CRs (74%) identified their program as University-Affiliated. Small, medium, and large programs were represented nationwide (Table 1). In an effort to maintain participant anonymity, data regarding the specific institution of each participant was not collected.
Table 1.
Characteristics of Pediatric Program Director and Chief Resident Resnondents
| Program Directors N (%)b | Chief Residents N (%)b | |
|---|---|---|
| Number of Respondentsa | 95 (47) | 210 (43) |
| Sex | ||
| Male | 34 (38) | 63 (31) |
| Female | 56 (62) | 134 (65) |
| Prefer not to answer | 0 | 9 (4) |
| No response | 5 | 5 |
| Age | ||
| ≤ 30 | 0 | 105 (51) |
| 31-40 | 11 (12) | 92 (45) |
| 41-50 | 40 (44) | 2 (1) |
| 51-60 | 21 (23) | 1 (0) |
| ≥ 61 | 18 (20) | 0 |
| Prefer not to answer | 0 | 6 (3) |
| No response | 5 | 4 |
| Current or Anticipated Career Path | ||
| Outpatient General Pediatrics | 29 (32) | 52 (25) |
| Pediatric Hospitalist Medicine | 36 (40) | 90 (44) |
| Pediatric Subspecialty | 20 (22) | 39 (19) |
| Undecided | 0 | 18 (8) |
| Other | 5 (6) | 7 (3) |
| No response | 5 | 4 |
| Geographic Region | ||
| Mid-America (West PA, OH, WV, KY, IN, MI) | 6 (7) | 24 (12) |
| Mid-Atlantic (Southern NJ, East PA, DE, MD, Washington DC) | 9 (10) | 13 (6) |
| Midwest (IL, WI, MN, IA, MO, KS, NE, OK, SD) | 21 (23) | 29 (14) |
| New England (ME, NH, MA, CT, VT, RI) | 9 (10) | 15 (7) |
| New York (NY, Northern NJ) | 10 (11) | 33 (16) |
| Southeast (VA, NC, SC, GA, FL, AL, MS, LA, AR, TN) | 9 (10) | 49 (24) |
| Southwest (TX) | 9 (10) | 12 (6) |
| Western (CA, NV, OR, WA, AK, CO, NM, UT, AX, HI) | 17 (19) | 30 (15) |
| No response | 5 | 5 |
| Type of Program | ||
| University-Affiliated | 74 (83) | 151 (74) |
| Community-Based | 11 (12) | 49 (24) |
| Military | 1 (1) | 1 (0) |
| Other | 3 (3) | 4 (2) |
| No response | 6 | 5 |
| Program Size | ||
| ≤ 30 | 23 (26) | 45 (22) |
| 31-60 | 33 (37) | 86 (42) |
| 61-90 | 23 (26) | 34 (17) |
| ≥ 91 | 11 (12) | 40 (20) |
| No response | 5 | 5 |
| Adolescent Medicine Fellowship at Current Institution | ||
| Yes | 25 (29) | 44 (21) |
| No | 62 (71) | 155 (75) |
| Unsure | 0 | 7 (3) |
| No response | 8 | 4 |
Ninety-five pediatric program directors and 210 chief residents answered the primary questions of interest.
Total counts and percentages were calculated from the total number of responses for each question; respondents were not required to answer demographic questions.
Current training practices
Formal training practices.
Sixty-six percent of PDs and 45% of CRs reported that their program provides formal training to residents on suicide risk assessment and management (Table 2). Of those with formal training, the majority (68% PDs, 67% CRs) reported that training was mandatory. Estimated total hours of training in residency varied: PD median=3 hours (IQR=1-4.5 hours), mean=4.2 hours (SD=7.0 hours); CR median=1.5 hours (IQR=0-3 hours), mean=3.2 hours (SD=7.5 hours).
Table 2.
Suicide Risk Assessment and Management Practices in Pediatric Residency Programs Identified by Program Directors and Chief Residents
| Program Directors N (%) | Chief Residents N (%) | |
|---|---|---|
| Formal Training Provided | ||
| Yes | 63 (66) | 94 (45) |
| No | 24 (25) | 85 (40) |
| Unsure | 8 (8) | 31 (15) |
| No response | 0 | 0 |
| Training is Mandatorya | ||
| Yes | 43 (68) | 63 (67) |
| No | 12 (19) | 26 (28) |
| Unsure | 8 (13) | 5 (5) |
| No response | 0 | 0 |
| Clinical Practice Guideline (CPG), Resource Document, or Departmental Policy Related to Suicide Risk Assessment and Management Used by Program as Reference | ||
| Yes | 19 (20) | 21 (10) |
| No | 48 (51) | 82 (39) |
| Unsure | 28 (29) | 107 (51) |
| No response | 0 | 0 |
| Suicide Risk Assessment Screening Instrument Used Within Training Program | ||
| Yes | 61 (64) | 145 (69) |
| No | 15 (16) | 36 (17) |
| Unsure | 19 (20) | 29 (14) |
| No response | 0 | 0 |
| Clinical Setting in Which Training is Provideda,b | ||
| Adolescent Medicine Rotation | 48 (76) | 54 (57) |
| Community Medicine Rotation | 6 (10) | 10 (11) |
| Continuity Clinic | 20 (32) | 45 (48) |
| Developmental and Behavioral Pediatrics Rotation | 13 (21) | 19 (20) |
| Emergency Medicine Rotation | 16 (25) | 14 (15) |
| Other (e.g., required educational conferences such as morning report, noon conference) | 26 (41) | 27 (29) |
| No response | 0 | 0 |
| Format of Training Provideda,b | ||
| Clinical Experience(s) | 33 (52) | 22 (23) |
| Case-Based Group Discussion(s) | 30 (48) | 31 (33) |
| Didactic Session(s) | 58 (92) | 81 (86) |
| Independent Reading/Journal Article(s) | 12 (19) | 19 (20) |
| Online Module(s) | 2 (3) | 11 (12) |
| Standardized Patient Exercise(s) | 2 (3) | 10 (11) |
| Other (e.g. informal training through routine patient care activities) | 3 (5) | 2 (2) |
| No response | 0 | 0 |
Total counts and percentages were calculated for program directors and chief residents who answered “yes” to “formal training is provided” (PD, n=63; CR, n=94).
Percentages do not add up to 100, as respondents were able to select more than one option.
Of survey respondents whose programs provided formal training, the most common setting was the Adolescent Medicine Rotation (76% PDs, 57% CRs). Other settings included Continuity Clinic (32% PDs, 48% CRs) and Other (e.g., educational conferences; 41% PDs, 29% CRs). The most common format was Didactic Instruction (92% PDs, 86% CRs) (Table 2).
CPG and screening instrument use.
Twenty percent of PDs and 10% of CRs reported their program used a CPG or policy document, 51% of PDs and 39% of CRs did not use one, and 29% of PDs and 51% of CRs were unsure. Guidelines reported by PDs (free text) included the PHQ-918 (n=5), institution-specific guidelines (n=4), and AAP guidelines9 (n=2). Use of a standardized screening instrument was reported by 64% of PDs and 69% of CRs. The most common instrument reported by PDs was the PHQ-9 or PHQ-2 (n=49), followed by the Child Adolescent Suicidal Potential Index (n=9). Sixteen percent of PDs and 17% of CRs did not use a screening instrument, and 20% of PDs and 14% of CRs were unsure (Table 2).
Perceptions of training importance and opportunities for additional training
Perceived importance and preparedness.
Eighty-two percent of PDs and CRs considered providing formal suicide risk assessment and management training “very” or “extremely” important (Table 3). Topics ranked highest in importance included: Identifying Risk Factors for Suicide (92% PDs, 89% CRs), Interviewing Patients about Suicide Using Clear and Direct Language (87% PDs, 87% CRs), and Locating Relevant Community Resources (86% PDs, 84% CRs).
Despite the above, only 18% of PDs and 10% of CRs reported their program prepares residents “to a great” or “to a very great extent” (Table 3). Top-ranked priorities for expansion were Interviewing Patients about Suicide Using Clear and Direct Language (61% PDs, 58% CRs), Identifying Risk Factors for Suicide (53% PDs, 52% CRs), and Locating Relevant Community Resources (54% PDs, 55% CRs).
Training format preferences.
Ninety-one percent of PDs and 90% of CRs believed training should begin in intern year. Case-Based Discussion was most desired (64% PDs, 50% CRs), followed by Online Modules for PDs (36% PDs, 24% CRs), and Evidence-Based Practice Guidelines for CRs (32% PDs, 37% CRs) (Table 3).
Perceived barriers to training and use
Top-ranked barriers to training were Lack of Time Due to Too Many Other Competing Topics (74% PDs, 72% CRs), Lack of Training Resources (49% PDs, 49% CRs), and Need for Additional Expert Faculty (45% PDs, 48% CRs). Four percent of PDs and 0 CRs responded No Barriers/Current Training is Sufficient (Figure 1A).
Figure 1A. Perceived Barriers to Curricular Implementationa.
a Percentages do not add up to 100, as respondents were able to select more than one option. Barriers represent respondents’ top two selections to ease interpretation of results.
Top-ranked barriers to consistent suicide risk assessment practices by residents were Time in Clinical Encounters (61% PDs, 71% CRs), Lack of Available Resources/Referrals (51% PDs, 37% CRs), and Lack of Clarity about Best Practices (42% PDs, 30% CRs). A minority of respondents (8% PDs, 11% CRs) identified Limited Effectiveness of Interventions as a barrier (Figure 1B).
Figure 1B. Perceived Barriers to Consistent Use of Suicide Risk Assessment and Management Practices By Pediatric Residents in Clinical Practicea.
a Percentages do not add up to 100, as respondents were able to select more than one option. Barriers represent respondents’ top two selections to ease interpretation of results.
Role of pediatricians content analysis
Identical themes and subthemes emerged from PD and CR responses to the open-ended question. Three primary themes were: (1) pediatricians play a critical role in suicide screening and risk assessment; (2) screening and triaging patients are necessary skills, but the management of suicidal patients may be beyond scope of practice; and (3) resources and curricula are desired. These, along with seven subthemes, are described in Table 4.
Table 4.
Content Analysis of Program Director and Chief Resident Perspectives on the Role of the Pediatrician in Suicide Assessment and Management
| Themes | Subthemes | Representative Quotations |
|---|---|---|
| Pediatricians play a critical role in suicide screening and risk assessment | Gatekeeper to referrals and community resources (e.g. psychiatry, psychology, social work, support groups) |
“Pediatricians are critical frontline providers and will necessarily have to participate in suicide risk assessment on a regular basis.” -PD “Pediatricians play a crucial role in identifying children and teens at risk for suicidal behaviors and setting them up with appropriate resources.”- CR |
| May be first and only individual to assess suicidality |
“We may be one of the few, if only, health care providers who sees the patient and who has the opportunity to assess for suicidality and depression.” - PD “We are part of the first line of defense and may be the only person asking a teen if they have thought of killing themselves.” - CR |
|
| Can be trusted patient allies and only person whom patients disclose risk |
“The pediatrician has a key role in assessing for suicide risk in their patients because patients trust their doctors and are more willing to confide those feelings to them.” - CR “Often the pediatrician is the only person the patient may disclose to - it is important for the pediatrician to then know how to best serve the patient once a disclosure is made.” - CR |
|
| Screening and triaging patients are necessary skills; management of suicidal patients may be beyond scope of practice | Must be trained to screen, identify risk factors and refer at-risk patients | “[Pediatricians] must be experts in identifying at risk patients and coordinating resources, whether that be acute hospitalization, mental health, psychiatry, home interventions, school interventions.” - CR |
| Management of suicidal patients may not fall within pediatrician’s role |
“Any acutely suicidal patient deserves a mental health expert to manage their treatment and shouldn’t be managed by the PCP.” - PD “Management doesn’t need to fall solely on the pediatrician – using community resources and psychiatry after identifying this risk can help make sure there’s a whole village watching out for that patient” - CR |
|
| Resources and curricula are desired | Evidence-based curricula standardized across pediatric residency programs are needed |
“I would love a curriculum or centralized standards we could implement nationally to ensure our residents are well informed about their role in suicide prevention and risk management.” - PD “Emergency department and adolescent medicine should be primary locations to institute a formal curriculum.” - CR |
| Development of curricula offers opportunity for interprofessional collaboration | “[This is a great] opportunity for interprofessional education/training – [we can] bring social work, psychiatry in to teach residents.” - PD |
PD = program director, CR = chief resident
Post hoc analyses
Reporting of formal training and total training hours did not differ by program geographic region, type (academic, community, military), or presence of an adolescent fellowship. Respondents from programs with an adolescent medicine fellowship were more likely to report CPG usage (X2=6.4, P=0.01).
PDs and CRs overall had high agreement on importance of different content areas. PDs were more likely than CRs to rate Identification of Risk Factors as important (MPD=4.6, SDPD=0.7 and MCR=4.4, SDCR=0.7; F[1,303]=6.4, p=0.01, η2=0.02). CRs were more likely than PDs to rate Pharmacologic Interventions (MCR=3.7, SDCR=1.0 and MPD=3.4, SDPD=1.0 respectively; F[1,303]=6.6, p=0.01, η2=0.02), Psychosocial/Behavioral Interventions (MCR=4.1, SDCR=0.8 and MPD=3.8, SDPD=0.9; F[1,303]=8.7, p=0.003, η2=0.03), and Postvention Practices (MCR=3.9, SDCR=0.9 and MPD=3.6, SDPD=0.9; F[1,303]=5.2, p=0.02, η2=0.02) as important for training.
Discussion
This study is the largest to date to describe suicide prevention training practices in pediatric residency programs nationwide from the perspective of PDs and CRs. We surveyed both PDs and CRs to solicit PDs’ unique understanding of their programs’ educational priorities, and CRs as a proxy for residents who have firsthand knowledge of training. Despite priority at the policy level for youth suicide prevention,2,3,9 and PD and CR endorsement as an area of high importance, formal pediatric residency training in suicide prevention does not appear universal. Research supports the efficacy of physician education for suicide prevention,8 yet median reported training estimates totaled 3 hours from PDs and 1.5 hours from CRs, and in many cases, was not mandatory. Additionally, although the majority (80%) of PDs and CRs rated such training as “very” to “extremely” important, a minority (18% PDs, 10% CRs) endorsed adequate preparation relative to training need. Taken together, our findings suggest variability across pediatric residency programs in training amount, format, and clinical setting, in addition to a mismatch between the perceived importance compared to time allocated to training.
Our findings align with prior research indicating a need for improvements to suicide prevention training among pediatric residents11,19 and pediatricians.12 For example, Sudak et al. found only 35% of pediatric PDs perceived resident training as adequate.11 Our findings expand on this research by including both PD and CR perspectives, characterizing training priorities, and identifying desired formats. Our results suggest agreement among PDs and CRs on three top areas for educational expansion: Interviewing Patients about Suicide Using Clear and Direct Language, Identifying Risk Factors for Suicide, and Locating Relevant Community Resources. PDs and CRs agreed Case-Based Discussion was the most preferred instruction format, despite the majority of current curricula utilizing Didactic Instruction. There were significant differences in PD and CR-reported importance of Identifying Risk Factors for Suicide, Pharmacologic Interventions, Psychosocial/Behavioral Interventions, and Postvention Practices; yet, overall both groups rated the importance of each of these topics relatively high and agreed on the importance of all other topics. These findings may point to initial targets for curricular reform.
CPGs in suicide prevention identify effective interventions including lethal means restriction20–23 and psychosocial interventions,24,25 both cost-effective interventions to reduce risk. CPGs could provide a structured framework for resident training based on a program’s curricular goals. Over half of PDs, however, reported no CPG use in training, and many were unsure about usage, suggesting variability in CPG visibility. This finding parallels content variability observed in CPGs across multidisciplinary fields13 and highlights the opportunity for development of best practices in curricula aligned with calls for increased uniformity in research and clinical practice26,27
The use of a standardized screening instrument in risk assessment is recommended by the AAP and has been found to aid risk detection,9,14,15,28 yet more than a third of PDs denied usage. The most frequently reported instrument was the PHQ-918, aligning with AAP recommendations.9 However, the PHQ-9 screens for depression and not other risk factors for youth suicide, including anxiety. Thus, use of other screening tools such as the GAD-2,29 which assesses anxiety symptoms, or suicide symptom screening instruments (e.g., Ask Suicide-Screening Questions (ASQ)), may bolster detection of at-risk youth. This is consistent with Joint Commission calls to screen for suicide risk in all medical settings.30 Indeed, research suggests routine assessment of psychiatric symptoms associated with increased suicide risk among youth (e.g., anxiety, insomnia)31,32 may enhance risk detection—critical to intervention and access to care. Given the impact of screening to guide intervention among youth,14,15,28,33 national initiatives, including the Zero Suicide Initiative within the National Alliance Action Plan for Suicide Prevention, prioritize calls for universal youth screening. Increased systemic study is needed, however, to evaluate screening approaches within diverse settings, especially primary care, as a suicide prevention strategy.34 Importantly, research focused on high-acuity settings such as the Emergency Department Safety Assessment and Follow-Up (ED-SAFE) study on ED screening, enhances risk detection, which aligns with the cost-effectiveness of brief triage and behavioral intervention strategies for suicide prevention.15,25 Together, these findings underscore potential benefits of additional research focused on CPG and screening tool use in residency training, building on policy guidelines in risk assessment and triage of at-risk youth.
Our findings highlight targets for educational improvements. First, the perceived importance of Pharmacologic and Psychosocial/Behavioral Interventions was rated lower than other areas, despite efficacy in reducing suicide risk.15,34 Interventions suggested by the AAP9 and others,16 including screening all adolescents for suicide risk factors including comorbid mood disorders, access to firearms, and interpersonal discord, have been highlighted as critical to include in pediatric education.7 Additionally, a minority of respondents indicated training was provided during the Emergency Medicine Rotation. Increases in suicide-related ED visits among youth4 and research suggesting high suicide risk post-hospitalization,35,36 underscore the value of providing training during this rotation. Interventions in ED settings including safety planning, discharge resources, post-ED phone calls and postcards have been found to reduce risk for suicidal ideation, attempts, and death by suicide.15,25,35
Notably, PDs and CRs did not prioritize Knowledge of Legal/Ethical Aspects of Suicide Risk Assessment and Management as an area for educational expansion. Ethical and legal challenges are inherent to suicide risk assessment. For the provider, risk assessment may introduce liability concerns, while confidentiality or hospitalization concerns may limit patient disclosure of suicidal ideation.37 CPGs recommend training in these areas,13 but additional research focused on training depth and quality is warranted. Best practices in safety planning and risk management models38,39 emphasize a collaborative approach to risk assessment, which may help alleviate such concerns. Indeed, development of suicide prevention curricula may ease ethical and legal concerns, while promising to enhance pediatric providers’ competence in managing at-risk youth.
Finally, critical to prevention, PDs and CRs believed pediatricians play a vital role in suicide risk assessment. Although self-reported attitudes do not necessarily reflect best practices, PDs and CRs showed similarities in the rated importance of training topics aligned with best practices, such as Identifying Risk Factors for Suicide, Triaging Patients Based On Risk, and Developing an Individualized Safety Plan. Nevertheless, PDs and CRs cited similar training barriers including Lack of Time Due to Too Many Competing Topics, Lack of Training Resources, and Need for Additional Expert Faculty. Importantly, respondents agreed that development of evidence-based, standardized training resources was necessary and offered opportunity for interprofessional collaboration. To address barriers and ensure programs provide suicide training despite time constraints, brief educational interventions including those utilizing or expanding upon existing resources, e.g., Suicide Prevention Toolkit for Primary Care Practices, are recommended.7,9,28,40
Based on our findings, additional training priorities may include resident instruction on the importance of uniform suicide screening, use of screening instruments, CPGs, lethal means restriction counseling, and indications and initiation of pharmacologic interventions.7,9,16 Instruction may be provided during Emergency Medicine, Adolescent Medicine, or Developmental-Behavioral Pediatrics rotations, as part of academic half-days, through conferences, or online modules. Consistent with suicide prevention initiatives,2,3 strategies to reduce youth suicide should also involve interventions that integrate physician education with other organizational approaches. As such, training incorporating information on local and national emergency resources including referrals for mental health providers, psychiatric social workers, and/or nurse case managers, as well as 24-hour crisis hotlines and text-lines (e.g., National Suicide Prevention Lifeline, Crisis Text Line), is recommended. Providing these resources could facilitate continuity of care and encourage interprofessional collaboration in suicide prevention.
Our study has several limitations. We accounted for formal training received, not informal training, which may have led to underestimation of training time. Additionally, selection and recall bias may have influenced our findings, and it is likely those who participated believed the topic was important. Using CRs as a proxy for residents offers insights into resident opinion, but may not capture differences in perspectives as residents advance through each stage of training. Although response rates of 47% and 43% for PDs and CRs respectively are relatively high and higher than prior pediatric PD response rates,11 findings may not be generalizable to all programs. Given survey anonymity, institutional affiliation was unknown and discrepancies in reporting between PDs and CRs from the same institution were therefore not possible to evaluate. Comparisons of PDs and CRs, therefore, are limited as samples are not truly independent and eta2s are small; further exploration using matched design is needed. Finally, results reflect surveyed versus actual training practices. Future research in suicide prevention residency education, building upon these findings and limitations, is recommended.
Despite these constraints, several strengths should be noted. Our survey was distributed through the APPD, the only organization of pediatric PDs and CRs for all U.S. residency programs. Participants were from a diverse range of programs, geographically and in size. To our knowledge, this study is the first to describe residency educational practices, including the training content and amount, as well as perceived training needs and priorities for curricula. We also expand upon prior studies by surveying both PDs and CRs, who offer uniquely important perspectives on resident training priorities. Our findings point to a need for standardized integration of suicide prevention training and curricular development aligned with policy recommendations 2,3,9
Conclusions
We found that suicide risk assessment and management training varies widely across pediatric residency programs in duration, format, and setting. Although respondents agreed that this education is critically important, a minority rated preparation as adequate relative to training need. Suicide among youth has emerged as a public health emergency and leading cause of death, and prevention has been identified as a national imperative. Our findings suggest key strengths in pediatric residency programs, including agreement between PDs and CRs on the perceived importance of suicide prevention training, training topics, and key barriers that may inform future research, development, and implementation of suicide prevention curricula.
Supplementary Material
IMPLICATIONS AND CONTRIBUTIONS:
Despite high perceived importance of suicide prevention training by pediatric residency program directors and chief residents, less than one fifth rated preparation as adequate relative to need. Training practices ranged widely across programs and formal training was not universal. Educational priorities and barriers were identified to guide future curricular development.
Acknowledgements:
The authors would like to thank the John A. Majda, M.D. Memorial Fund, Association of Pediatric Program Directors (APPD), and the Stanford University School of Medicine Department of Pediatrics Residency Program for their support of this investigation.
Funding: This study was supported in part by grants K23MH093490 from the U.S. National Institute of Mental Health (Dr. Bernert) and by the John A. Majda, M.D. Memorial Fund from University of California San Diego (Drs. Schoen and Bernert). The funding for this work had no involvement in the conduct of this research, study design, collection, analysis, interpretation of data, preparation of the article, or decision to submit the article for publication.
List of Abbreviations:
- AAP:
American Academy of Pediatrics
- ACGME:
Accreditation Council for Graduate Medical Education
- APPD:
Association of Pediatric Program Directors
- CR:
Chief Resident
- CPG:
Clinical Practice Guideline
- ED:
Emergency Department
- PD:
Program Director
Footnotes
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Previous Presentations: This work was previously presented as a poster at the Association of Pediatric Program Directors (APPD) Annual Spring Meeting on March 22, 2018 in Atlanta, Georgia and the Pediatric Academic Societies (PAS) Meeting on May 6, 2018 in Toronto, Canada.
Disclosures/Conflicts of Interest: None
Contributor Information
Lucy E. Schoen, Email: schoenle@sutterhealth.org.
Alyssa L. Bogetz, Email: abogetz@stanford.edu.
Melanie A. Hom, Email: hom@psy.fsu.edu.
Rebecca A. Bernert, Email: rbernert@stanford.edu.
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