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Slide 1: Professional Perspective, Audience and Topic.

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Slide 1: Professional Perspective, Audience and Topic.

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Currently, I serve as an Assistant Director for Advising and Career Development in undergraduate medical education.  I assist medical students, pursuing doctorates in medicine with advising and career development. The topic of my legal guide is suicide prevention in undergraduate medical education and privacy. The audience for this topic would be faculty, staff and medical school administrators at undergraduate medical institutions.  I chose this topic because of my role and undergraduate medical education, and because according to the American Medical Association (AMA), medical students are three times likely to die from suicide than the general population (Murphy, 2019).  As a profession in student development, understanding the legal and ethical implications of this topic is a high priority.

Citation:

Murphy, B. (2019, June 12). How often do physicians and medical students die from suicide?  American Medical Association (AMA).

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Two in five physicians screen positive for depression and mental health issues, and burnout and other stressors are prominent across the continuum of physician education and practice. Medical students, meanwhile, are three times likelier to die of suicide than their counterparts in the general population, according to data cited in an AMA Council on Medical Education report presented at the 2019 AMA Annual Meeting.

The AMA House of Delegates (HOD) adopted the council report's call for the Association to work to better understand the routine occurrence of burnout, depression and suicide among physicians, residents and medical students.

"It is vitally important that we take action now to fully understand the actual impact of suicide on our physician workforce. Our goal is to have access to data that will help us identify the systemic patterns and risk factors that lead to suicide, and ultimately help us prevent it," said AMA Board Member S. Bobby Mukkamala, MD. "We will continue working to reduce burnout and increase access to mental health services for physicians and physicians-in-training-improving their well-being and leading to better health outcomes for their patients."

The AMA will:

Explore the viability and cost-effectiveness of regularly collecting National Death Index (NDI) data and confidentially maintaining manner of death information for physicians, residents, and medical students listed as deceased in the AMA Physician Masterfile for long-term studies.

Monitor progress by the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education to collect data on medical student and resident or fellow suicides to identify patterns that could predict such events.

Support the education of faculty members, residents and medical students in the recognition of the signs and symptoms of burnout and depression and support access to free, confidential, and immediately available stigma-free mental health and substance use disorder services.

Collaborate with other stakeholders to study the incidence of and risk factors for depression, substance misuse and addiction, and suicide among physicians, residents and medical students.

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How often do physicians and medical students die of suicide?

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Two in five physicians screen positive for depression and mental health issues, and burnout and other stressors are prominent across the continuum of physician education and practice. Medical students, meanwhile, are three times likelier to die of suicide than their counterparts in the general population, according to data cited in an AMA Council on Medical Education report presented at the 2019 AMA Annual Meeting.

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Physician burnout and suicide are topics that have been researched for several years, however, there has not been a lot of emphasis on the specific triggers in undergraduate medical education.  Although there are initiatives that focus on undergraduate education, it is important to identify the unique needs of students who are navigating through the rigorous process of medical school in pursuit of becoming physicians.  This is important in undergraduate medical education because literature indicates that physicians are experiencing burnout, depression and suicide earlier in their careers, many during their residency training (occurs between medical school and becoming fully licensed physicians). Professionals in undergraduate medical education are in a position to play a much more significant role in providing resources and support for this student population who are at a higher risk of suicide.

An emerging issue related to suicide prevention and privacy in undergraduate medical education is the increasingly competitive nature of how medical school success is defined.  A medical student’s success is defined by their ability to obtain a residency position, the next step of training required for any medical student to become a physician.  With residency programs becoming more selective in whom they are choosing for training, and the limited number of spots that do not accommodate all medical student graduates, medical students do not feel comfortable taking care of their mental health needs for fear that the perception of needed mental health assistance may reflect negatively on them. This hesitation from medical students mean that faculty and staff need to be better equipped to identify high-risk students and take the proper protocol, while considering privacy laws, to ensure students get the help they need.

Citation:

Grossman, D. (2016, September 27). Reducing the sigma: Faculty speak out about suicide rates among medical students, physicians.  American Medical Association (AMA).

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The young physician was so critically depressed that the family cat would not come near him, according to the doctor's wife. She felt safe disclosing this to Jay Lynch, MD, a professor of medicine at the University of Florida College of Medicine, because he is one of a very few physicians to publicly reveal struggles with depression and suicidal thoughts. Lynch has shared his story on KevinMD.com; NPR's Weekend Edition; and TheConversation.com.

Higher suicide rates among physicians than in the general population are widely documented. How much higher is not clear because solid data are lacking, experts agree. But Srijan Sen, MD, PhD, an assistant professor of psychiatry at the University of Michigan Medical School and the principal investigator of the Intern Health Study, a longitudinal study of depression among interns nationwide, estimates "suicide rates among physicians are something like 40 to 70 percent higher in males and 130 to 300 percent higher in women."

Among medical students, suicide is the second most common cause of death, after accidents. A study published in the February 2009 issue of Academic Medicine found that 13.6 percent of medical students exhibited probable major depression and 6.6 percent reported suicidal ideation.

Lynch shared his own experience with depression and suicidal thoughts in 2014 after two interns in New York City jumped to their deaths within days of each other. He explained that a dozen years earlier as a physician in his 40s, his life had all the trappings of success but he was depressed.

"[Depression] is a malignancy of the mind," he observed. "It disables our ability to see it in ourselves." He got as far as planning how to make his death appear to be an accident rather than suicide.

What pulled him back from the brink was a friend's expression of concern. In 2002, at the funeral of a college classmate, Lynch's friends talked about struggles in their lives. "I sat mute, listening," Lynch wrote on TheConversation.com. "Then one of my friends turned to me and asked, 'How about you, Jay? You're awfully quiet.' I knew I finally had a chance to be honest.... I muttered something like 'Not too well, I think.'"

As soon as he got home from the funeral, Lynch called a psychiatrist friend. "She asked me, 'What is it you're so afraid of?' I said, 'All I do is disappoint people.'... As false as that was objectively, that's the way everything felt." But his turnaround was swift. "My response to antidepressants was so dramatic, it's hard to articulate it," he said. "Within seven to 10 days, I felt like a new person."

Physicians' medical knowledge does not make them immune from the stigma of suicide. Last fall, Lynch decided to tell his story to help break the logjam of silence. "It shouldn't be that this is such a taboo subject in an era when anybody who knows anything about physiology realizes that neurotransmitters and neural networks are how we think and feel," he said.

Similarly, medical schools across the country are addressing the issue head-on. "Increasingly, schools are sensitive to the fact that there are students who may be at risk," said Geoffrey Young, PhD, AAMC senior director for student affairs and programs.

At the same time, general wellness is receiving growing attention, with AAMC-member institutions "educating student communities, as well as faculty and administrators, about the importance of work-life balance," Young noted. He cited advising and mentoring structures, such as the Indiana University School of Medicine's College and House program, as "a safety net" for students. In addition, Vanderbilt University School of Medicine has numerous extracurricular activities that give students downtime and a chance to socialize.

"Students should participate in activities outside of medicine, maintain personal connections, and make their own physical health a priority," said Scott Rodgers, MD, former associate dean of student affairs at Vanderbilt.

Since Lynch revealed his own safety net, he has heard from more than 100 people moved by his story. One was the wife of the physician with depression so deep that the cat sensed it. About a month later, Lynch said, the physician's wife told him that her husband was "not perfect but he's better-and the cat sits in his lap now."

Reasons for the higher suicide rate

Physicians and medical students typically are slow to understand their anguish. "Physicians are very cautious about acknowledging these feelings and about getting help," said Diane Roston, MD, a clinical assistant professor of psychiatry at Dartmouth's Geisel School of Medicine. "Physicians often struggle with these thoughts all by themselves for much longer [than non-physicians]," she said.

The reasons for this paint a distinctive picture of depression. One, ironically, is that physicians can be even more susceptible than non-physicians to feeling shame about suicidal thoughts. "It's a proud population," said John Greden, MD, executive director of the University of Michigan Comprehensive Depression Center and past president of the American Foundation for Suicide Prevention. "It's not part of the culture. We don't want to acknowledge vulnerabilities; we're supposed to be on top of everything."

Another factor, Lynch noted, is that physicians, more than people in other professions, fear that admitting to suicidal thoughts will affect their livelihood. "They're often afraid they won't be able to practice, they'll lose privileges," he said.

While that fear may be imaginary, two very real aspects of physicians' work also play into their hesitation to seek help. First, the stress and emotional intensity of caring for others can render physicians less able to care for themselves. Medicine is "a tough job, and the responsibility of caring for patients can be an overwhelming job," Young pointed out. Second, carving out time for treatment from a busy clinical schedule proves insurmountable for some physicians.

In addition, physicians have more knowledge than the general public about effective means to achieve death. "If the attempt is lethal," Greden noted, "you don't get a second chance." This factor is credited as the reason female physicians have a higher rate of suicide, compared with women overall. In the general public, more women than men attempt suicide, but men are more apt to choose a lethal method. Women physicians, however, know just as well as their male peers how to take their lives.

The most important factor in physicians' higher suicide rate is their "fearlessness about the physical ordeal" of death, explained suicidologist Thomas Joiner, PhD, the Robert O. Lawton Professor of Psychology at Florida State University. Humans' fear of death "is deep in our DNA," he said. "[Fear is] a huge barrier to death. It happens every day that people are consumed with the idea of suicide up until the very last instant when that fear kicks in and saves them."

Roston, too, believes fearlessness is the principal factor in the suicide rates of physicians. "No matter what field of medicine you're in, you've had exposure to physical trauma, and that desensitizes you to blood and injury and toxicity," she said. That is why, she and others noted, police officers, firefighters, EMTs, nurses, and members of the military also have higher than average suicide rates.

Search for solutions

Despite the apparent complexity of the problem, experts suggest down-to-earth solutions such as talking about the problem, normalizing it to dispel the stigma, reaching out to troubled colleagues, and taking care of one another.

One essential step is shining the light of day on the issue through more physicians telling their stories, according to Lynch. "If enough people come forward, there will be more who will be willing to acknowledge their struggles," he said.

Recognizing that depression is a disease is very important, Young noted. "Try to reduce the stigma and create an environment where [depression] isn't viewed as a weakness," he said. That type of environment is the rationale for initiatives such as the Mayo Clinic's Physician Well-Being Program, which provides resources to promote wellness and fosters personal and organizational approaches to preventing physician distress.

Medical schools and teaching hospitals are actively working to prevent suicides by cultivating a learning environment that is supportive when mental health issues arise. Many are educating students and faculty about the risk factors and warning signs that could precede suicidal thoughts. In addition, there has been a push to screen for fatigue and burnout throughout the education continuum and during medical practice.

The Accreditation Council for Graduate Medical Education requires that programs provide confidential counseling for trainees who may be experiencing suicidal ideation. To ensure anonymity, medical schools have implemented policies that separate mental health services from the academic environment.

Approaches should include "making it clear that [the problem] won't affect people's careers and licensing," Sen observed. Those struggling with depression "often think they're alone," he added. "If people would realize that many of their colleagues and friends are going through this as well, they could help support each other in better ways."

"If people would realize that many of their colleagues and friends are going through this as well, they could help support each other in better ways."

Srijan Sen, MD, PhD

Such support can be as low-key as asking colleagues if they are okay. Greden compared it to a peer-to-peer model that has been successful in getting military veterans to seek mental health care. "We trust each other, we take care of our own" is the way veterans explain it, Greden said. "These are conditions that are treatable, but not if the person doesn't get treatment. That's the biggest hurdle we face."

The key is "to get people talking, so they realize, 'Oh, I'm not alone,'" Lynch said. "That first crack in the door can come from anybody they trust. A trust factor has to be part of this."
This article originally appeared in print in the September 2015 issue of the AAMC Reporter.

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Reducing the Stigma: Faculty Speak Out About Suicide Rates Among Medical Students, Physicians

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The young physician was so critically depressed that the family cat would not come near him, according to the doctor's wife. She felt safe disclosing this to Jay Lynch, MD, a professor of medicine at the University of Florida College of Medicine, because he is one of a very few physicians to publicly reveal struggles with depression and suicidal thoughts.

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The American Association of American Colleges (AAMC) is a professional organization in undergraduate medical education.

This is an informative resource for suicide prevention in undergraduate medical education because it provides a toolkit in the form of a webinar that offers valuable information for professionals in medical education to create a culture of wellness.

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The facts about mental health and suicide in the academic medicine community are sobering. Physicians and trainees have higher rates of burnout, depressive symptoms, and suicide risk than the general population. A 2015 meta-analysis of 17,500 residents over 50 years estimated that 28.8 percent of resident physicians experienced significant depressive symptoms. Another prospective intern cohort study found that 24 percent of interns developed suicidal thoughts within three months of starting their internships. Yet ironically, doctors are less likely than other members of the public to seek mental health treatment.

"Tolerating the culture of silence was no longer an option. We realized it was up to us to fight the rising tide of suicide among our own."

I became interested in the subject of physician suicide as a psychiatry resident at the University of California, San Diego, School of Medicine (UCSD), when a fourth-year medical student I knew took his life. I was shocked. How could his internal suffering or turmoil have gone unnoticed?

As I progressed in my own career, eventually becoming a professor of psychiatry and assistant dean for student affairs and medical education, I increasingly noticed that mental health and the concept of self-care as a vital component of being a good physician weren't truly integrated. Speaking up about psychosocial realities in our patients, let alone in ourselves, wasn't always a welcome part of the lexicon.

Why do physicians have high rates of distress?

Physicians have traditionally lived within a culture of silence when it comes to mental health. Loathe to draw attention to self-perceived weakness, we commonly cloak experiences of anxiety, worry, or shame and carry out our mission. We rationalize significant distress as part of our identity as physicians. While a certain amount of bucking up and forging through is adaptive, this coping strategy can go too far, ignoring serious deterioration of mental health.

There are multiple barriers that keep physicians and trainees from accessing mental health care-confidentiality concerns, time constraints, or uncertainty about whether treatment would improve things. Some physicians have often unfounded or outdated worries about the potential for negative ramifications on one's reputation, licensure, or hospital privileging. Lastly, like many high-functioning, driven professionals, we often have a blind spot that keeps us from clearly recognizing the seriousness of mental health changes in ourselves.

Not seeking help when we become overwhelmed can lead to disillusionment with our work, burnout, and serious conditions, including major depression, anxiety disorders, and substance use problems. Another potential downstream consequence is self-medicating. A 2013 postmortem study of data from the Centers for Disease Control and Prevention National Violent Death Reporting System revealed that physicians who died by suicide have 20-40 times the rate of benzodiazepines, barbiturates, and antipsychotic medications in their systems than nonphysicians, which points to self-treatment. Not getting the help we may need can also lead to disrupted personal relationships, a higher likelihood of medical error in practice, and an increased risk for suicide.

Over a period of 15 years at UCSD, we lost more than 10 physicians and trainees to suicide. As happens for many communities, we reached a tipping point when a prominent and very revered faculty physician took his life. Collectively, we realized that tolerating the culture of silence was no longer an option.

Putting the focus on mental health: How UCSD stepped up

With support from both medical school and hospital leadership, we formed a multidepartmental team at UCSD to tackle suicide prevention. We modeled our efforts, in part, on the evidence-based strategy of a U.S. Air Force program that achieved an astonishing 33 percent reduction in suicides between 1996 and 2002. Air Force leadership addressed the importance of recognizing changes in mental health, and policy changes protected the privacy and professional reputations of those referred for help. The Air Force program taught members how to intervene at the first signs of distress, possibly long before an imminent risk of suicide, and to recognize more acute warning signs of suicide risk.

We adopted a similar approach at UCSD, highlighting stigma reduction as a central tenet in our educational efforts, along with policy changes that promote a safe, supportive culture and encourage rather than penalize seeking help. Our goal was to create a safety net for recognizing suicide risk and preventing suicides. We instituted the Interactive Screening Program, a confidential web-based tool created by the American Foundation for Suicide Prevention. The tool enables individuals to take a brief stress and depression questionnaire anonymously, and then, also confidentially, talk with a counselor online, by phone, or face to face.

Our efforts at UCSD had great success and are still going strong. More than seven years later, 180 physicians and trainees at UCSD have accepted referrals for mental health care, with the majority saying they would not have done so on their own.

Achieving this culture of safety takes a concerted effort from the top down, as well as a willingness to be attuned to ourselves and one another, to ask for help when we need it, and to proactively identify those same needs in our colleagues and trainees. It is critical that we speak out and model a view of mental health that gives it the same legitimacy and value as physical health.

Addressing our own physical and mental health needs allows us to remain highly competent and resilient. By shifting the lens to focus on mental health, we will reap positive outcomes-from lowered rates of angst, desperation, burnout, and suicide to enhancements in well-being and clarity of mind. We can experience a greater sense of meaning and connection to our work, our patients, and one another. The outcome will be stronger, healthier physicians, better able to serve the needs of those we treat.

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Creating a Safety Net: Preventing Physician Suicide

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The facts about mental health and suicide in the academic medicine community are sobering. Physicians and trainees have higher rates of burnout, depressive symptoms, and suicide risk than the general population.

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This recent article focuses on medical student burnout and the correlation to depression and suicide. It discussed the implications of depression and suicidal ideation on medical students' and their ability to take care of patients.

The historical nature of undergraduate medical education is self-sacrifice as opposed to self-care, and is often supported by seasoned physicians who have a difficult time relating to the current state of medical student stressors.

There are medical schools who are being proactive in identifying stressors in the curriculum, and developing programming and training to help prevent depression and suicide among student doctors.

Citation:
Choi, A.K. (2019, August 29).  Medical education needs to stop burning out students - now.  StatNews

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tudents' time in medical school should help them grow and become insightful, caring doctors. Instead, medical education is somehow turning smart, gifted, enthusiastic applicants into exhausted and unhappy students who become interns, residents, and physicians at increased risk of depression and burnout.

I'm no stranger to the demands of medical school. My father and father-in-law were both doctors. I'm a pulmonologist, my wife is a nephrologist, and we have a son who is an internist and another who is in medical school. These issues are personal to me. As the dean of a medical school, they also focus my efforts to modify the learning environment to keep pace with new generations of students.

As difficult as it is to quantify, my sense is that medical education seems vastly more rigorous and traumatic for students today than it was for me, and possibly for the generations before me.

In a 2014 study from the Mayo Clinic and Stanford University, more than half of all U.S. medical students had symptoms of depression, and 56% reported themselves to be burned out. The same study found that medical students were two to five times more likely to have clinically significant depression than similarly aged college graduates pursuing other careers. Indeed, a 2016 meta-analysis showed that the rate of depression in medical students in 47 countries was 27%, far higher than rates in the general population.

This raises concerns about how effectively medical students with psychological distress will take care of future patients. It also invites the question of how medical education contributes to this disturbing trend.

For many generations of students, medical school has traditionally promoted a culture of self-sacrifice over self-care. Pressure to perform academically is relentless. Reaching the point of being able to practice medicine is the overriding focal point, even in the face of frustration and fatigue over long hours studying a tremendous volume of complex information, learning to treat patients, and tackling other unfamiliar challenges.

Compounding the problem, students entering medical school have long been accustomed to being the best academically, but soon discover they're surrounded by others who are equal, or even better, academically. Though successful, many get overwhelmed - an experience that law students, biomedical graduate students, and other professional students also relate to.

Students can easily lose track of why they wanted to become doctors in the first place. They may see any admission of vulnerability or exhaustion as signs of inadequacy compared to their peers. And those who get depressed or anxious often feel ashamed, doubt their own abilities, and tend to keep it to themselves instead of seeking professional help.

The good news is that some medical schools and professional societies are taking steps to improve well-being and resilience among students. They're taking closer looks at whether current learning environments are a major contributor to the problem. Educators are paying particular attention to common stressors in medical education, including the curricula, the role of standardized testing and competition among peers, and the transition to residency, to assess if academia is keeping pace with the ways newer generations learn or function. The common goal is to more fully recognize and understand issues such as burnout and adapt the system to better support students, residents, and physicians alike.

Take the mental health care program at the University of Pittsburgh School of Medicine, a progressive approach described last year in the New England Journal of Medicine. About 1 in every 6 students there receive mental health care services. Students need this kind of outlet, in which they can feel comfortable opening up, seeking support, and breaking through the silence that accompanies stigma.

At Weill Cornell Medicine, where I work, the number of medical students reaching out for appointments with psychiatrists has increased by about 60% in the past four years. And we have expanded our free counseling and mental health services to match this rising need.

My conversations with deans and administrators at other medical schools informally confirm this promising trend in medical education. In addition to more medical students getting the treatment they need for emotional difficulties, including medication or talk therapy, more are coming to better understand the humbling experience of being a patient and increase their capacity for empathy.

Next month, as a modest next step, Weill Cornell will host the first National Conference on Medical Student Mental Health and Well-Being, in partnership with the Association of American Medical Colleges, the Associated Medical Schools of New York, and the American Foundation for Suicide Prevention. Medical school administrators and faculty members, mental health professionals, students, and others will convene to identify innovative approaches to resilience training and mental health treatment that can be implemented at medical schools around the country.

But we need to do much more to reform the medical education system. The central challenge is to help students develop resilience.

First, schools should integrate comprehensive wellness and mental health support into the learning environment. One strategy Weill Cornell Medicine plans to implement is to assign all medical students to advisory groups that include physician wellness mentors. These coaches can act as role models for coping with adversity and stress during the training period and beyond.

Second, medical schools should commit to documenting and reporting anonymized data about psychological distress among medical students. This will help further destigmatize it, allow us to better understand its causes and extent, and develop new solutions.

Third, medical schools should evaluate shifting to a pass-fail grading system. A major source of stress for medical students is academic. The competitive pressure to achieve top grades and honors runs directly counter to establishing healthy relationships among peers. Many institutions are already moving toward a pass/fail approach during all four years of medical school, according to the Association of American Medical Colleges.

Fourth, researchers should conduct studies to pinpoint the causes of mental health issues among medical students - and, equally valuable, trace any links, internal and external, between stressed-out students and burned-out physicians. Teasing out cause and effect could enable institutions to better promote clinician resilience.

Despite these challenges, I'm optimistic. Medicine remains one of the most respected professions and continues to attract talented, idealistic students eager to make a difference. The millennials now enrolled in medical school are generally more willing than prior generations to admit to facing stress and seek help, and are more likely to see burnout as systemic rather than fault themselves for an inability to cope.

It's past time for adding the dimension of self-care to formal and informal medical education curricula. Only if medical students learn to take care of themselves will they ever truly excel at caring for others.
Augustine M. K. Choi, M.D., is the dean of Weill Cornell Medicine and provost for medical affairs at Cornell University.

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Medical education needs to stop burning out students - now

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Medical education should help students become caring doctors. Instead, it is somehow puts them at increased risk of depression and burnout.

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A well known university changed their Leave of Absence (LOA) policy to address the needs of students who suffer from mental health.

The change was prompted by a class action law suit from a student who suffered from mental health issues, who according to their previous LOA policy was discriminated against, under ADA.

This is an important current event, because it will most likely change how higher education will approach not only addressing mental student health, but will also play a significant role in suicide prevention services and resources on campuses.

Citation:
Anderson, G. (2019, October 8). Fair leave for mental illness. Inside Higher Education.

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Stanford University will change its leave of absence policies to better accommodate students who are facing mental illness crises. The decision, which goes into effect next year, results from a settlement agreement with a group of students who say they were prodded to leave campus by administrators.

The coalition of Stanford students sued the university last year to change its involuntary leave of absence policy, arguing that it barred students from the university after incidents where they were deemed to present a risk to themselves or others, instead of providing solutions to keep them in classes, according to the complaint. Several students named in the class action lawsuit attempted suicide then had their university housing privileges revoked, or they were threatened with expulsion if leave was not taken.

On Monday, Stanford announced it would rewrite its Involuntary Leave of Absence and Return Policy and put new procedures into effect by the university's winter term. The revised policies will more closely determine "whether modifications or reasonable accommodations exist that could help the student remain on campus and/or in class," Susie Brubaker-Cole, Stanford's vice provost for student affairs, wrote in a message to students.

Rather than providing adequate resources to help students with mental illness disabilities continue their education, Stanford was encouraging them to leave campus as a "first resort," said Maia Goddell, supervising attorney for Disability Rights Advocates, which represented the students. In the lawsuit, students recalled that they were treated like a "liability" to the university and felt discouraged from reaching out to Stanford's counseling and psychological services in times of crisis.

Students with mental health disabilities soon will be able to petition to remain in campus housing during their involuntary leave, as students with medical disabilities currently can, according to the settlement, which Stanford and the student coalition mutually agreed to. The university also will hire additional staff and provide more training to assist students with mental health disabilities, according to a statement from Disability Rights Advocates.

Under the new guidelines, students who opt to take voluntary leave from Stanford will be able to revoke their decision within two days. And when a student who was on leave is ready to return, the Office of Accessible Education can provide "reasonable accommodations" for the re-enrollment process, according to the new policies. Students with mental illness disabilities took issue with "personal statements" they were required to write to be reinstated at Stanford, which included taking responsibility for their actions -- an inappropriate requirement for a student who self-harmed, Goddell said.

Stanford is also in a four-year partnership with the Jed Foundation, an organization that several colleges and universities have hired to evaluate and improve mental health, substance use and suicide prevention resources.

The settlement is "historic" and the first of its kind, according to Disability Rights Advocates. The group is optimistic that other colleges and universities will follow Stanford's changes and implement their own policies to improve the experiences of students with mental health disabilities.

"We would really hope that other universities will look to that and consider what they can do to support, rather than punish, students who have mental health crises," Goddell said.

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Stanford changes leave policies on mental illness

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Stanford University will change its leave of absence policies to better accommodate students who are facing mental illness crises. The decision, which goes into effect next year, results from a settlement agreement with a group of students who say they were prodded to leave campus by administrators.

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Slide 6: Family Educational Rights and Privacy Act (FERPA)

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Slide 6: Family Educational Rights and Privacy Act (FERPA)

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FERPA has a statutory law component and an administrative law component that  applies to educational institutions and student privacy rights.

In an attempt for any educational institution to offer services such as suicide prevention or training to better identify at risk students, FERPA guidelines would need to play a role in how student information is handled, who has access to it, and when it can be released.

In addition to educational records, student health records are also protected under FERPA and consent from the student is needed to release the information.  However, in dealing with suicide prevention, there is some flexibility in the law where student consent isn't needed under specific conditions; one of these conditions is if there is a health concern and or safety emergency.

Citations:
20 U.S.C. § 1232g
34 C.F.R. § 99.31(a)(10)  and § 99.36

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Slide 7: American Disabilities Act (ADA)

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Slide 7: American Disabilities Act (ADA)

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Similar to FERPA, ADA is also statutory law with an administrative law component.  Disability Law protects students from discrimination based on disability status; mental health would also be covered under this law.

For suicide prevention programs, this would be an important law to identify what actions would need to be taken in order to ensure a student will not face any discrimination based on disclosure of their mental health status in order for a suicide prevention program to be effective.

However, in order for professionals in higher education to abide by the law, while attempting to properly train administrators in suicide prevention, understanding the "Direct Threat" portion of this law allows appropriate individuals to "take action" or using the assessment of a student's actions to intervene is there is a threat to harm themselves or others.

29 C.F.R. § 1630.2(r)

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Home > About EEOC > History > 25th Anniversary of the ADA > ADA Resources

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This section of the Texas Education Code is a state law that was passed in TX to ensure that students entering an academic teaching institution must receive information related to mental health and suicide prevention.

This would support the justification for suicide prevention and focus on undergraduate medical education.

The law specifies   to include students in professional degree programs, which would also cover the needs of students in medical education.

Citation:
Tex. Educ. Code § 51.9194

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Bill Title: Relating to a requirement that certain entering students at a general academic teaching institution receive information regarding mental health and suicide prevention services.

Spectrum: Partisan Bill (Democrat 4-0)

Status: (Passed) 2015-06-18 - Effective on 9/1/15 [SB1624 Detail]

Download: Texas-2015-SB1624-Enrolled.html

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Bill Title: Relating to a requirement that certain entering students at a general academic teaching institution receive information regarding mental health and suicide prevention services. Spectrum: Partisan Bill (Democrat 4-0) Status: (Passed) 2015-06-18 - Effective on 9/1/15 [SB1624 Detail] Download: Texas-2015-SB1624-Enrolled.html

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A case that is important to reference when it comes to interpretation of the law as it relates to the "duty" university administrators to protect students from suicide is one that was argues this case.

Nguyen was a 25 year student in graduate studies at the Massachusetts Institute of Technology when he died by suicide after a difficult conversation with a professor.

The student had a documented history by the school of mental health issues, and had attempted suicide.  The Nguyen family felt that the institution did not to enough, with the information they had, to protect the student from themselves.

This case is also relevant to privacy issues related to suicide prevention, because the student asked repeatedly not to disclose his mental health background (suicide attempts) in an effort to keep his academics separate from his mental health obstacles.

The "special relationship" in legal liability is also references this this case.

Citation:
Nguyen v. MIT, No. SJC-12329, 2018 Mass. LEXIS 249, *19 (Mass. May 7, 2018)

Pepper Hamilton LLP. (2018, May 15). Dissecting the massachusetts ruling recognizing a duty for higher education institutions to prevent student suicide. JD Supra Legal News.

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A recent decision by Massachusetts's highest court unanimously recognized that, under some circumstances, colleges and universities have a duty to protect students from suicide that, if violated, could result in tort liability. While the court's opinion provides a framework for determining the scope of this potentially expansive new duty, its precise contours remain unclear and raise important questions for educational institutions. Notably, the decision marks a departure from several prior cases that have not recognized this duty, and it is unclear whether other states will follow Massachusetts's lead. Nevertheless, the decision counsels that all educational institutions should review their policies and practices related to students at risk of self-harm.

Nguyen v. MIT involved the 2009 death of a 25-year-old MIT graduate student who died by suicide immediately after he was scolded during a phone call with a professor concerning the tone of an email that he sent. The student, who lived off campus, had a lengthy history of mental health issues that included two prior suicide attempts in 2002 and 2005, and he regularly sought help for depression from professionals outside of MIT during his time as a student. Although some of his mental health issues were known to MIT employees, including a dean who knew of his prior suicide attempts, the student repeatedly made clear that he wished to keep those issues separate from his academic work. Accordingly, the professors in his program were unaware of his history of depression or suicide attempts.

In determining if these facts could support a negligence claim, the court analyzed whether there is a duty to prevent suicide. This "duty" analysis is critical because it serves as a gatekeeping role for the court (not a jury) to decide the extent to which the law can reasonably impose liability for the consequences of certain forms of conduct. While the question of whether a duty exists is one for the court to decide, generally a jury must decide whether that duty has been breached. And the reality is that once a case gets to a jury, schools face a substantial risk justifying their conduct against the horrors of a tragic event - even when schools act with the best of intentions.

The court in Nguyen explained that ordinarily there is no duty to prevent suicide, but one can arise if there is a "special relationship" between the parties. These are typically found in the context of custodial relationships, such as hospitals to patients or jails to inmates. Indeed, the lack of custody in the educational context has been one reason why some courts have previously declined to identify a special relationship and thereby a duty to prevent student suicide. In Nguyen, however, the court reasoned that, while higher education institutions lack the parent-like relationship that educators of younger students have, they "are clearly not bystanders or strangers in regard[] to their students." Accordingly, when a "university has actual knowledge of a student's suicide attempt that occurred while enrolled at the university or recently before matriculation" or "stated plans or intentions" to die by suicide, then it must take reasonable measures to protect the student. When an institution has a suicide prevention protocol, reasonable measures include initiating it. In the absence of a protocol, reasonable measures require employees to contact the appropriate campus resource to obtain clinical care when they learn of a student's plans or recent attempt to die by suicide. If the student refuses care, his or her emergency contact must be notified. Applying that duty to the facts before it, the court ruled that, at the time of the student's suicide, there was no duty because no MIT employee had actual knowledge of present suicidal ideation or prior suicidal acts that were sufficiently recent to the student's matriculation.

The decision marks the second state high-court decision this year broadening the duties owed to college and university students through the finding of a special relationship. The Nguyen court's recognition of the existence of this duty and the extensive discussion regarding the contours of the duty and how it is satisfied are also somewhat remarkable, given that the facts of the case clearly came outside the scope of the duty that the court created. Thus, while the decision has some sweeping discussion, it is almost all dicta, and the precise circumstances under which the duty will arise and its reach will require extensive future development by courts.

For instance, is the duty truly triggered in every case involving a somewhat recent suicide attempt regardless of other factors? While the court viewed this as a substantially narrowing feature of the duty, sadly, prior suicide attempts by university students are not unusual. Does the duty apply even when the student has been found by a treating physician to be stable? Does the duty apply to other potentially self-harming behaviors, like eating disorders? Moreover, while MIT was able to avoid liability because the faculty did not have actual knowledge of the student's plans or a recent suicide attempt, the ruling does not fully develop what constitutes "actual knowledge." The court sought to reign in the obligation nonclinician faculty and staff may have to identify suicidal tendencies by emphasizing the limited nature of the duty. But in the complicated situation of a distressed student communicating suicidal thoughts to a nonclinician employee, where "should have known" stops and "did know" begins may itself generate litigation.

What is the precise scope of the duty if it exists? A narrow reading of the case may only require institutions to initialize an existing protocol to avoid liability. But a broader reading invites adjudication of the protocol itself. This in turn may require juries to grapple with complex policy questions (and expert testimony) concerning mental health treatment as they assess the reasonableness of a particular protocol. Is there a duty to ensure that the health professional who is contacted is competent? What happens when the emergency contact does not agree that the student's behaviors exhibit a substantial risk?

Nguyen's concern with the problem of suicide on campus is spot on. But the reality is that most colleges and universities take the problem incredibly seriously, including making use of teams of professionals who are well-trained in this field. The question is not whether the issue is an important one, but whether the appropriateness of a response should be put in the hands of a jury, potentially subjecting schools to huge monetary awards. Schools already are navigating several laws in this area, including the obligation not to discriminate against those with mental health disabilities - itself an evolving area of the law awaiting clarification from the Department of Education and the Department of Justice. Indeed, the Nguyen court implicitly recognized its holding opens the door to the issue of discrimination under the Rehabilitation Act. While the court was sympathetic to the burden the duty may put on institutions that learn an incoming student has recently attempted suicide or plans doing so, the court still recognized that colleges and universities cannot discriminate against students on this ground. As the court remarked later in its opinion, "[t]he burden on the university is not insubstantial, but so is the financial benefit received from student tuition."

The contours of potential tort liability will become clearer as the ruling is analyzed in future cases. And other states may well decline to follow Massachusetts's lead. In the meantime, the decision calls for colleges and universities to take a critical look at their existing suicide prevention and other self-harm protocols to make sure they incorporate best practices. Just as important, the decision's focus on employee and faculty knowledge of a student's suicide attempt or plan means it is vital to ensure employees are well-educated on how to identify at-risk students and are given clear guidance on how to quickly call to action professionals on campus to address these complex questions.

Endnotes

See, e.g., Rogers v. Christina Sch. Dist., 73 A.3d 1 (Del. 2016) ("Since [the student's] suicide took place while he was at home and not on school grounds, the School no longer had custody[.]"); see also Jain v. State, 617 N.W. 2d 293, 297 (Iowa 2000) (noting that plaintiff conceded that "university's relationship with its students is not custodial in nature" and thereby no duty could be established on that ground); but see Schieszler v. Ferrum Col., 236 F. Supp. 2d 602 (4th Cir. 2002) (plaintiff alleged sufficient facts to support claim that a special relationship existed between decedent and defendants where student lived on campus and defendants knew decedent threatened suicide); Shin v. MIT, 2005 Mass. Super. LEXIS 333 (Mass. Super. Ct. 2005) (finding that special relationship existed between MIT administrators and decedent and that defendants could reasonably foresee that decedent would hurt herself without supervision).

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Dissecting the Massachusetts Ruling Recognizing a Duty for Higher Education Institutions to Prevent Student Suicide | JD Supra

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A recent decision by Massachusetts's highest court unanimously recognized that, under some circumstances, colleges and universities have a duty to protect students from suicide that, if violated, could result in tort liability. While the court's opinion provides a framework for determining the scope of this potentially expansive new duty, its precise contours remain unclear and raise important questions for educational institutions.

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HSC's Privacy Policy Practices outlines the specific policies related to student privacy and details how student medical information is used.

This local policy was selected because it ensures students understand how and when their information will be accessed, who can access it, and what their rights are as it relates to their medical information and privacy.

Citation:
Privacy Policy. UNT Health Science Center, 4 Jan. 2017. Accessed 28 April 2020.

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The UNT Health Science Center is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information.

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In the Council for the Advancement of Standards in Higher Education (CAS), the ethical principle of Non-Malfeasance, which translates as a pledge to do no harm.  Administrators on all levels of higher education have the best intentions, but non-malfeasance relates to the topic of suicide prevention and privacy because educators need to be intentional about their efforts to do no harm through prevention because suicide is too late.

Citation:
Council for the Advancement of Standards in Higher Education. (2019). CAS professional standards for higher education (10th Ed.). Washington, DC.

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Higher education institutions in Texas are abiding by the law in providing information to all students about suicide prevention and mental health as required by TX Senate Bill 1624.  The site below outlines the Suicide Prevention Program in undergraduate medical education (HSC of Fort Worth).

Citation:
Suicide Prevention Program.  UNT Health Science Center, 31 March 2020. Accessed 30 April 2020.

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Suicide Prevention Program - Office of Care and Civility

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The Office of Care and Civility collaborates with The Jordan Elizabeth Harris Foundation to offer Suicide Prevention Training - Question, Persuade, Refer (QPR) on our campus. We incorporate QPR training into our Suicide Prevention Week.

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Slide 13 (Part One): Recommendations and Best Practices for Compliance

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Slide 13 (Part One): Recommendations and Best Practices for Compliance

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Complete a needs-assessment at your institution to pinpoint stressors for the student population.

Implement an action plan for stressors caused by the campus culture or curriculum, or other factors related to the student process.

Create a document or guide that outlines details related to FERPA, and in particular the areas that govern consent to release information and when consent isn't needed.

Create a document or guide that outlines details related to ADA and in particular, direct threat options in navigating perceived or potential harm that a student may cause themselves.

Target and compile a list of medical school administrators who are integral in student development, and schedule training to inform them of the stressors and needs of their students.  Include case studies to discuss duty to protect, and defining the "special relationship" universities have with students.

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Slide 13 (Part Two): Recommendations and Best Practices for Compliance

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Slide 13 (Part Two): Recommendations and Best Practices for Compliance

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Collaborate with suicide prevention specialist to gain knowledge in recognizing the signs of depression, suicidal ideation, and other behvaiors such as imposter syndrome.

Include the university's legal counsel in protocol, when administrators need to assess taking action against a student, where it may infringe upon privacy  and discrimination laws (as a reaction to a perceived threat from mental health and/or suicide prevention).

Create a local school policy that is accessible to faculty, staff, and students that will help them understand their rights to privacy as well as how the university may use information related to health.

Ensure that there is a centralized place both online or electronically, and through the compliance office that is updated annually.

Find ways to shape programming around suicide prevention that aligns with the CAS ethical principles to ensure continuous improvement and progression in the application of mental health awareness and suicide prevention.