Perceived Stalking by a Patient: An Educational Case Report

Mr. AS, a young man with a history of personality disorder with antisocial, borderline, and histrionic features, was admitted under court order for evaluation and potential psychiatric treatment after making provocative and murderous statements to his school counselor about a classmate. AS had a history of stalking and threatening this classmate, including breaking into the classmate's home on multiple occasions. After careful diagnostic evaluation, AS was kept in the hospital involuntarily for 13 months under the care of a team including resident physicians rotating on the service. AS expressed anger and animosity toward the team's residents for continuing to hold him against his will. Several residents worried that AS might engage in retaliatory behavior and were distressed to realize that their personal information was easily and publicly accessible through online voter registration and public property records.

Approximately 1 year after discharge, AS unexpectedly appeared at the front door of the home of one of the trainees (RY) involved in his hospital-based care. Neither AS nor RY acknowledged their previous clinical relationship, and AS said he was there for piano lessons with RY's roommate. The encounter left RY shaken. Had AS arrived by chance, or had he come with piano lessons as an alibi for premeditated harm? Should RY warn his roommate?

RY consulted with his coresidents, who were similarly alarmed, before he reached out to his residency program director for advice. His program director validated his concerns, reinforced his professional duties, including attention to patient privacy and confidentiality, and arranged for mentorship with a staff forensic psychiatrist. The forensic psychiatrist reviewed RY's medicolegal options and provided support to RY as he thought through them. Ultimately, RY elected to monitor the situation, as did most of his colleagues; one was motivated to install a home alarm system for enhanced safety. None of the residents (all of whom have since completed training and moved to other states) have had further contact with AS.

Promoting resident well-being is a complex and multifaceted task that demands attention to psychological and physical safety in addition to traditional facets of well-being and self-care. We have identified 4 major categories to consider when working to optimize resident well-being (Box).

Residents may have difficulty recognizing supports available to them. Shame and uncertainty may prevent help-seeking.^7,8  In the specific situation described with AS, trainees did not initially articulate their safety concerns to their program director, relying instead on peers for support and advice.^9-15  While it is absolutely important for GME program directors to refrain from participating in medical or psychiatric care of their trainees, it is also important for program directors to foster an environment of psychological safety in which trainees are able to seek guidance in situations when they are unsure of appropriate next steps.^16-22  In times of trainee distress, it may be necessary for program directors to adopt an approachable and multifaceted role (eg, validating concerns, arranging further counsel),^23,24  placing evaluative functions as secondary until appropriate mentorship can be identified.

Trainees may feel conflicted in trying to reconcile ethical patient care with personal safety, or they may lack full knowledge of the system of care. Also, particularly when patients are criminally involved, trainees may accurately recognize gaps or liabilities in the system. The residents caring for AS would have benefited from more holistic, intentional supervision with explicit consideration of their specific ethical and treatment concerns. Because trainees encountering difficult patient interactions may feel “split” in reconciling these concerns, close, regularly scheduled, and specific supervision with an invitation to discuss ethical challenges and emotional reactions to patient situations can optimize patient care as well as resident safety.^25-29 

It is helpful for program directors to refer their trainees for specific mentorship in topics that lie beyond their own professional expertise.^12,30  In the case of Mr. AS, trainees had specific personal safety concerns and were balancing moral, ethical, and legal issues. For this reason, it was important for the program director to identify an expert in legal aspects of patient care to provide mentorship, guidance, and feedback.

In an era of easily accessible online information, physicians in practice and training alike will be well served by proactively guarding their personal information and digital footprint. It can be jarring and distressing to realize after the fact that personal information, including names of family members, home address and cost, and participation in various community activities, is easily retrievable through simple online searching. We recommend specific instruction, including lessons on how to scrub a digital footprint, how to adjust social media privacy settings,³¹  how to recognize stalking behaviors, how to file a police report or restraining order, and how to maintain awareness of resources and rehabilitative interventions for criminal offenders.³² 

The moment of realization that a patient may be stalking a health care provider is anxiety-provoking and potentially traumatic. Shame, self-doubt, and lack of clarity regarding roles and expectations may result in delayed help-seeking. The scenario described with patient AS may serve as a starting point for residency program directors to prepare and support trainees by promoting psychological safety, regularly scheduled and intentional supervision, targeted mentorship, and explicit discussions about online footprints and ways to safeguard personal information.