Deciding to Refer Residents for Psychiatric Evaluation

A chief resident reports to the program director that a resident has “not been himself lately,” as he abruptly seems more withdrawn and less talkative during conferences. The program director asks this resident's supervising faculty member if she has noticed anything. The supervisor confirms the chief resident's observation, and adds that the resident currently is late in completing progress notes, and that the notes are much shorter than before. The supervisor has mentioned these observations to the resident, but there has been no improvement.

This scenario is not uncommon in residency training. While it might represent transient stress, it may indicate deeper psychological problems or a psychiatric disorder. The dilemma for program directors is when, and how, to properly refer residents for psychiatric evaluation. The American Medical Association considers it the ethical duty of all physicians “to take cognizance of a colleague's inability to practice medicine adequately by reason of physical or mental illness.”¹ The exact prevalence of mental illness among physicians is unknown, but the existing, limited studies indicate that rates of depression are higher among medical students and residents than the general population.^2–4 Suicide rates among practicing physicians are significantly higher than the general population, especially for female physicians.⁵ A recent study found that the factors contributing to suicidal ideation may differ between residents and physicians in academic practice,⁶ but that all physicians are less likely to seek help.⁷ It is therefore important for program directors to know how to respond when questions arise about the mental health of their residents.

In response to concerns about physician impairment, states have established physician health programs to monitor physicians impaired by addiction or mental illness. State Medical Boards require that any impairment be reported and referred to a physician health program.⁸ In addition to the ethical and state regulatory concerns regarding physician impairment, residents are covered by the Americans with Disabilities Act of 1990 (ADA). In Shaboon v Duncan,⁹ a medical resident asserted that her rights under the ADA were violated when she was terminated from training after failing to submit documentation that she was fit to see patients. The resident had been referred for psychiatric evaluation by her program director following an incident in which the resident thought other residents were laughing at her. The psychiatrist urged the resident to voluntarily admit herself for treatment. After admission, the resident changed her mind, left treatment, and attempted to return to training. She subsequently was suspended and then terminated. While the Fifth Circuit Court of Appeals dismissed the claims against the program director and the psychiatrist, it upheld the plaintiff's ADA claim against the hospital and ruled that it was not immune from ADA liability. The decision focused on whether the hospital had documented the resident's inability to perform her duties, rather than requiring the resident to provide evidence of psychiatric clearance for work.

Therefore, programs and sponsoring institutions must consider how to prepare for and conduct referrals of residents for psychiatric evaluation. Since many physicians are reluctant to seek help on their own, programs must provide training to residents and faculty on the responsibilities, risks, and resources in dealing with impaired physicians. All residents and faculty should know how to confidentially report any concerns. The institutional procedures established for handling physicians with substance abuse issues can provide useful guidance on documenting and handling residents with psychiatric illness. It is important for program directors to be aware of institutional resources, such as employee assistance programs and physician health committees, as well as physician well-being programs that exist at some institutions. It is also helpful to identify psychiatrists in the community who are able to evaluate and treat physicians; residents may prefer the additional privacy of seeking mental health care outside the institution.

Most important, the sponsoring institution's offices of graduate medical education and human resources must provide guidance to residents and programs. Sponsoring institutions should ensure that health insurance and disability coverage for residents includes provision for mental illness. There are also many available resources on the topics of depression and physician suicide; these include the Accreditation Council for Graduate Medical Education Initiative for Physician Well-Being¹⁰ and the American Foundation for Suicide Prevention.¹¹

For situations in which a resident's behavior or performance has prompted concern, the program director should schedule a private meeting with the resident to present specific concerns and to listen to the resident's response. While there may be a single incident in question, the concerns raised are often about a pattern of behavior. The decision frequently confronted by program directors in these situations is whether a psychiatric evaluation should be mandatory or merely a suggestion to seek help. If the resident's problems compromise patient care, block progress in training, or violate institutional policies, then a psychiatric evaluation may be required, as these concerns outweigh a resident's right to privacy. A program director should emphasize that these problems are not necessarily career-ending when dealt with appropriately. If a resident is already seeing a therapist, it is best to have an independent psychiatric evaluation focused on fitness to work. Otherwise, a request for the resident's therapist to conduct an evaluation would create a conflict of interest and potentially undermine treatment (box).

The requested psychiatric evaluation should only address the question of the resident's ability to return to training and any potential accommodation necessary for treatment. If the psychiatric evaluation is mandatory, the appropriate consequences for noncompliance should be considered and presented to the resident in advance. Depending on the reasons for making the evaluation mandatory, the actions for failure to comply might include suspension from clinical duties, suspension or nonpromotion in training, or nonrenewal of the training contract. Medical boards may require reporting of any psychiatric treatment for licensed physicians and residents on training permits, and programs must help residents comply with these regulations. Program directors must balance these ethical and regulatory concerns with respect for resident wellness and the need to ensure patient safety.

Many factors contribute to decisions by physicians suffering from mental illness to not seek appropriate treatment and care. It is the responsibility of graduate medical education to not only help those residents struggling with mental health problems, but also to train all residents to be aware of these issues and how to best address them so that residents, and physicians in general, can find paths toward wellness. The rate of physician suicide is a clear warning that more must be done to address the mental health problems in this population. This work must be a priority for the graduate medical education community.