When a Resident or Fellow Dies.

“I am afraid I have some very bad news.” In May 2016, we learned that one of our trainees had died unexpectedly. While we hope that other programs will not need to reference this, we describe below what we learned.Beyond creating an environment of academic and clinical excellence, program directors and academic leaders need to be aware of the psychological and physical health of our trainees and coworkers.1 We monitor trainees for signs of burnout, substance use, depression, and suicidal ideation; teach fatigue mitigation techniques; and offer mental health services,1 all within the context of a 24/7 clinical service.What happens when—despite our best efforts—one of our trainees or junior faculty colleagues dies?2,3 The death of a trainee can be a crisis for a program or department. This article provides tips for managing this tragedy.Residents, fellows, and staff expect the program director and other academic leaders to guide them through the emotional and practical aspects of the grieving process. People watch our actions and level of empathy.4 How we manage and present ourselves in this type of crisis affects our organization's culture and our own standing in the workplace.5 The table outlines matters that may need the leader's attention. It is organized by time: immediate steps first, followed by longer-term considerations.People will want to know what happened, but the deceased trainee retains privacy rights under the Health Insurance Portability and Accountability Act of 1996. We cannot reveal the cause of death without permission from his or her next of kin. This may require a series of discussions with the family, as they may need time to consider what to share and with whom. How the trainee died will affect how we frame the news (table).6–8 The program director may find it helpful to rehearse and review the phrasing with a trusted colleague before sharing more broadly.This type of news is best conveyed in person with all the residents gathered.9 Meeting as a community decreases the sense of isolation and provides a platform for sharing feelings of loss.10 It creates a visual reminder that the trainees are part of a supportive community.How one starts delivering the information matters. First, reassure trainees that the program is secure. This will allow them to focus on the critical information conveyed.11 After sharing the bad news, the leader may choose to give voice to the range of emotions he or she is experiencing.12 The program director's modeling of appropriately expressed emotions allows others to follow suit. Trainees may need permission to express anger at the deceased.13Trainees may recall their last moments with the deceased, and wonder if they should have noticed something or should have acted differently. Physicians strive to protect the vulnerable and may feel unrealistic guilt about not having prevented the death.14Experiencing and expressing a range of emotions and then returning to care for patients can be disorienting. In retrospect, we wish we had discussed this challenge explicitly with our residents. Physicians are expected to perform and place their patients' needs before their own. Performing dual roles—grieving and working simultaneously—can be difficult.13After the initial shock, trainees may ask in various contexts, “What about me?” They may worry about the impact on the program's reputation or how much call they may need to absorb.The more profound What about me? question may take the form of “If this person can die, and he or she was so accomplished, then what about me?” These thoughts may not be voiced. Again, we wish we had anticipated these questions and addressed them directly. The program director should address What about me? with reassurance—right after the announcement of the passing.11After this acute period, how trainees feel may not be apparent. On the surface, things “return to normal.” But people's grief may be “disenfranchised,” meaning not freely expressed and repressed.10,13We did not foresee disenfranchised grief and its consequences. Some residents craved an opportunity to share stories14,15 and felt isolated if they kept these stories to themselves. The baseline strain of training, compounded by isolation and increased call responsibilities, may cause some trainees to suffer and become “second victims.”14 They can feel empty or experience waves of grief.21 Some trainees' health may deteriorate such that they cannot work or take call. Absenteeism may rise,10 placing an additional strain on the other residents. Medical errors may increase.22We wish we had predicted the risk of trainees' prolonged grief and complicated bereavement. It may have been helpful to discuss this risk openly, encourage trainees to seek help, or organize an additional team-building day. Helping people “make sense” of the loss and “bearing witness” to their pain, and not just saying, “Move forward,” are important to help prevent feelings of burnout.8,14,15,22,23This is a fine line to navigate. Some trainees will want to move forward and will find inquiries intrusive. Other trainees may need to be asked multiple times before they feel comfortable describing their pain. Knowing who needs what can be challenging.Best practices from the organizational leadership literature support flexible time for grieving employees or gradual reentry into the workplace.22 How to balance trainees' need for grieving time with the service's need to staff emergency room shifts is a challenge.1,13Grief may stir as the anniversary of the death approaches.23 Anniversaries can affect well-being and even mortality.24 Planning to mark the anniversary can ease anxiety, yet it presents its own dilemmas. While the impulse may be to create a named seminar series, for instance, there will come a time when all of the deceased's peers have graduated. A second option is to create something permanent, such as a plaque or award given at graduation, but residents may not want the reminder. It may help to survey trainees anonymously for their preferences.Throughout this entire experience, people will watch leadership and observe how skillfully leaders communicate decisions and how faithfully they support others. This can weigh heavily on leadership. The program director should try to connect with other leaders who have experienced a death in the program.Another way the program director or academic leader can maintain well-being is by reaching out3 and expressing love. We choose to be educators because we love to teach and have a desire to pass along the wisdom we have.3 While a trainee's death is a painful tragedy, it also can be an opportunity to grow, connect, and love.