When patients die: patient memorials and group reflection in an internal medicine residency program

Abstract

Patient death is a formative and emotional experience for physicians. Medical trainees are particularly susceptible to the emotional impact of patient death. However, few studies have examined how trainees process patient death. This study describes annual patient memorials organized at a large multisite academic graduate medical education program. Peer-led, 1-hour patient memorial services were organized for internal medicine residents, including large and small group reflection, a moment of silence, and collective art projects. At the conclusion of each memorial, participants completed a 10-question survey regarding their experience during the memorial and their prior experiences with patient death. Ninety-nine surveys were analyzed over 2 years. Of resident respondents, 84% reported feeling comfortable or very comfortable participating in the memorials, and 93% rated reflection on patient death as important or very important. When asked how they reflect on patient death, 67% of residents reported processing patient death independently, while only 23% reported processing patient death with their medical teams. Patient memorials with small and large group discussions are easily adopted and replicated. Residents reflect on patient death frequently but often independently rather than with their medical teams. Patient memorials provide a venue for collective mourning and group reflection to support trainees.

Patient death is an inescapable aspect of medical practice. Prior studies have found that physicians frequently experience psychological distress and feelings of failure related to patient death.^1,2 Physicians often first encounter patient death during medical training, but few studies have investigated how trainees process these losses.³ Prior studies concluded that trainees feel unprepared to manage their feelings about patient death and often cope with patient death in isolation.^4–7 A survey of internal medicine residents attending a memorial service at a single institution found that trainees believed reflection on patient death was important and that patient memorials helped generate reflection and closure.⁸ We designed resident-led annual memorials at our multihospital training program, collected attendee feedback, and surveyed trainees about patient death. This educational innovation seeks to meet the need within graduate medication education for residents to process death in a learner-centered fashion.

METHODS

In February of 2016 and 2017, resident leaders organized patient memorials at each of the three major teaching hospitals in our internal medicine program at Baylor College of Medicine. Each 1-hour memorial occurred during a routine educational conference such as morning report or noon conference. We invited all teaching faculty, internal medicine residents, and students on internal medicine inpatient teams to attend, and participation was optional. The event was publicized via e-mail and through chief residents’ announcements during morning reports leading up to the event.

A resident opened each memorial by showing a 3-minute video about the importance of human connection in patient care. We then invited attendees to share a patient death experience with the large group; to encourage large group sharing, we requested that several residents prepare stories ahead of time. Afterwards, we split attendees into small groups of approximately four to seven people to continue sharing reflections using optional discussion prompts projected on a screen (see Supplemental Material). Small groups were randomly assigned to encourage intermingling between training levels, and no official moderator was assigned to each group. In closing, a resident or faculty member shared a final reflection and facilitated a moment of silence during which attendees held electric candles. We then shared information about emotional support resources and invited participants to write a remembrance on a group collage art project.

We distributed a voluntary, 10-question paper survey to participants at the conclusion of each memorial, which had been iteratively reviewed by faculty members for face validity (see Supplemental Material). The survey asked about experiences with patient death, methods of reflection, and feedback on the memorial. We analyzed survey responses using descriptive statistics. The Baylor College of Medicine institutional review board approved the study and waived the need for formal consent.

RESULTS

During 2016 and 2017, 149 and 157 residents, respectively, rotated on all inpatient services during February. Approximately 100 faculty, residents, and students combined attended the patient memorials annually, with about 20 to 40 attendees at each hospital’s event. We collected 185 total surveys in 2016 and 2017; 53% (99) of survey respondents were residents, 38% (70) were students, and 9% (16) were faculty (Table 1). Attendance was not taken to encourage a safe environment for sharing.

Table 1.

Survey respondents by level of training^a

	2016	2017	Totalb
Students	37	33	70 (38%)
PGY-1	22	30	52 (28%)
PGY-2	11	10	21 (11%)
PGY-3	11	14	25 (14%)
PGY-4	1	0	1 (<1%)
Faculty	11	5	16 (9%)
Total	93	92	185

^aSurvey respondent data from all three hospitals are combined for each year.

^bPercentages represent percent of total number of survey respondents.

PGY indicates postgraduate year.

Of resident respondents, 84% reported feeling comfortable or very comfortable participating in the memorial. Survey participants were also asked how they value reflection on patient death. Of the 99 resident respondents, 93% rated reflection on patient death as important or very important. In addition, 71% of residents believed it was important or very important to have protected time away from clinical duties for reflection on patient death. Open-ended comments described the memorials as “great” or “excellent.” Several requested more frequent patient memorials and noted a significant need for such events. Others mentioned that they ran out of time to share, and some found the memorials “too emotional” and were “afraid [they] would cry.”

When asked how frequently they reflect on patient death, 32% of residents reported reflecting daily or weekly. Trainees were asked to select the manner in which they process patient death, with permission to select more than one option (Figure 1). Notably, 67% of residents reported processing patient death independently and 54% with friends or family, while only 23% reported processing with their medical teams.

Figure 1.

Residents’ response to the question “How do you usually process a patient’s death?” Respondents were able to select all applicable answers. Data were combined from 2016 and 2017 survey results.

Regarding constructive feedback, several respondents reported greater ease sharing personal stories within the small group format. After the first year, all patient memorials included a small group discussion. Some indicated preferring to reflect without sharing aloud, which prompted the inclusion of group collage art projects as a mode of commemoration.

DISCUSSION

We created a peer-led, discussion-based memorial in our residency program to provide a forum for sharing experiences with patient death. Sessions included both large- and small-group discussions as well as a moment of silence and an art project. A majority of residents felt comfortable participating in the sessions, and most residents agreed that protected time for reflection on patient death is important. The memorials have become established annual events in our program and have remained a resident-led initiative. The simplicity of the event format allows the memorials to be easily replicated each year with different resident leaders, and four other residency programs at our institution have since adopted the memorials. Since the onset of the COVID-19 pandemic, the patient memorials have also been transformed into a digital format.

Nearly all our resident survey respondents deemed reflection on patient death important, but interestingly, most trainees described processing patient death alone, with a minority of them debriefing with their teams. Some residents also commented that intense emotions during the sessions made it difficult for them to actively contribute. These data resonate with studies indicating that physicians who experience negative patient outcomes are at risk of a “second victim” experience and sense of shame, which can lead to social isolation, an impaired sense of belonging, and decreased wellness.^7,9–12 While it is unclear why residents often cope with death in isolation, fear of failure, guilt, and a lack of time dedicated to reflection likely contribute. Initiatives such as Schwartz rounds and Balint groups focus more broadly on the provider-patient relationship, while our patient memorial format provides a unique experience for trainees to discuss patient deaths with peers without requiring significant time, resources, or faculty leadership for implementation.^13,14 Patient memorials offer an opportunity for collective grief and mourning. Each resident who steps forward to share encourages another trainee to do so as well.

Limitations of this study include the use of a nonvalidated survey instrument and implementation at a single institution. Lack of attendance tracking also limited our ability to accurately determine the survey response rate among attendees. In addition, participation in our event was voluntary, which may have introduced selection bias into our results, as trainees more interested in participation were more likely to attend. Future directions for this work include evaluating the impact of patient memorials on learner wellness and reflection practices. Increased frequency of memorials was often requested by attendees but was challenging to implement. Further assessment of the value of implementing quarterly or biannual memorials would be useful. In addition, our results suggest a lack of team-based reflection on patient death. Prior research has investigated the utility of debriefing sessions such as “death rounds.”⁷ However, further investigation is warranted to determine how to make team debriefing a more integrated part of residency programs.

In conclusion, annual patient memorials with small and large group discussions were well received and easily replicated in a large, multihospital internal medicine residency program. Residents reflect frequently on patient death and most often do this in isolation. This resident-led program innovation provides allotted time and structure to create a safe environment for reflection on patient death with a community of peers.