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Physicians study how to heal patients. But they also need to learn how to grieve their loss.
Physicians devote their careers to improving and preserving their patients’ health and longevity. But along with the success and fulfillment physicians often derive from practicing medicine, grief and loss permeate the profession as well. In the traditional culture of medicine, the latter emotions are not just undiscussed, but also poorly understood.
“Medicine is one of those things that you’re (culturally) supposed to do every day with a badge of honor, and just keep doing it harder,” says Mohana Karlekar, MD, FACP, FAAHPM, medical director of palliative care and assistant professor in the department of general internal medicine and public health at Vanderbilt University Medical Center. But given the risks of professional burnout, compassion fatigue and chronic stress, physicians need to take a more realistic approach to coping with loss, she says.
“As a palliative care physician, (I see) a lot of people die who are very sick, and my primary care practice has quite a few palliative care patients,” she says, noting that the grief process is somewhat different with predictable deaths and those that are sudden. Likewise, some physician-patient relationships are long-term, while some are episodic.
However, they all have an impact that’s crucial for physicians to recognize and acknowledge, she says.
Just a week before being interviewed by Physicians Practice, Karlekar cared for two young adults who died unexpectedly - one in a house fire and the other from a new onset of heart failure. “I didn’t know them before this week, but there’s grief in that,” she says. For Karlekar, it helps to talk about grief, let others know about it and to practice self-care through exercise.
However, it’s rarely possible for physicians to take those steps immediately after a loss. “Sometimes, you’ve got to get to the next patient or the next task, and you don’t have the time or space to process. Try to find some time in your life to go back and deal with it,” she says. “Because if you ignore it, it tends to come back at you in different forms.”
Physician practice leadership plays a substantial role in creating an environment in which all members feel safe acknowledging their emotions, says Christine Moutier, MD, chief medical officer of the American Foundation for Suicide Prevention. Rocked by the suicide of a fourth-year medical student during her psychiatry residency at the University of California, San Diego, Moutier has spent her career training healthcare leaders, physicians and patient groups to improve the healthcare system’s approach to mental health, fight stigma and optimize care for those suffering from mental health conditions.
“It was such a shocking and jarring experience of confusion and grief,” she says of her classmate’s death. “(As physicians, we) really hold ourselves to an irrational sense of responsibility for all things. You think you should have been able to see it coming,” she says, adding that loss survivors in general tend to criticize themselves for missing a suicide victim’s distress.
In terms of preventing suicide as well as helping healthcare teams recover from grief and loss, it’s the responsibility of every school, training program and workplace to create a culture that is safe and respectful, Moutier says. “People must get ongoing signals that are not just top-down, but that are actually being lived out. (It must be clear) that this is a place where every person is valued and respected and where you can get your needs met in a healthy, proactive manner.”
Karlekar agrees, adding that there is no one-size-fits-all framework to promote emotional health. “The assumption can’t be that at 2 o’clock on Friday, let’s all talk about our feelings,” she says. Individuals have varied comfort levels and needs, which she says should be honored.
“Right now, one of my nurse practitioners is seeing a lot of 20-year-olds on the trauma unit,” Karlekar explains. To help lessen the emotional toll, Karlekar has made time to converse with her via text. “Some of it is just, ‘Hey, how are you doing? Do something nice this weekend.’”
Another technique practices can adopt is to create a quiet room in which clinicians and staff can take a few moments to reflect, meditate, complete paperwork or simply take a breather.
In some cases, Karlekar invites members of her healthcare team to gather in the aftermath of loss. “We have had some intentional debriefs when things have been really tough or when someone who touched everyone has died,” she says. “I had a patient with cystic fibrosis who died a week before his 30th birthday. Our floor team had been taking care of him for about five years. We had counselors come in and meet with the nurses.”
Leeat Granek, PhD, associate professor at York University’s School of Health Policy and Management in Toronto became interested in learning more about physicians’ grief after losing her mother to breast cancer in 2005. Throughout the nearly 20 years her mother lived with the disease, Granek says she developed very intense relationships with the healthcare team. “I started to wonder after she died what happens to all of these relationships that suddenly get severed.”
As a result of interviewing many oncologists who had lost patients in their care, Granek has gathered empirical data about the types of support they would like to help them cope with grief and loss in the workplace. Top requests included training during residency and fellowship about how to cope with patient death, having their emotions validated and vacation time to recharge.
Whatever the options, they must be non-stigmatized, Granek says. “Oncologists said they didn’t talk about this because they thought emotion was a stigma and that they would be considered weak or vulnerable if they showed emotion.”
One of her recommendations, therefore, is to have oncologists opt out of interventions rather than opt in. Examples of wellness offerings may include gym memberships, mindfulness classes or one-on-one counseling. “It reduces the stigma because it’s the expectation and the norm that everybody participates in one of these things,” Granek says.
While Granek’s work is specific to oncology, it provides a previously unseen glimpse into physicians’ thoughts and feelings about patients’ setbacks, suffering and death. In one of her studies, published in JAMA Internal Medicine in 2012, Granek and colleagues discovered that when oncologists lose patients, their sense of loss is two-fold. Not only do they experience “normal” symptoms of grief such as sadness, fatigue and missing the person who died, but they also struggle with a profound sense of personal responsibility as well.
“The oncologists were talking about things like a sense of powerlessness, failure and guilt - and those things are particular to this context where the physician really feels responsible for the patient’s life,” Granek says.
In comparison, she explains, “When my mother died, I didn’t really feel a sense of failure or powerlessness because I had no responsibility or control over whether she died.” Of course, physicians don’t bear this burden either, she says. “They do their best and hope the treatment is going to help the patient, but whether it does or not is ultimately not in their control.”
Nonetheless, physicians’ feelings of failure don’t just compound their grief. They also influence future patient care, such as by avoiding end-of-life conversations, delaying palliative care or choosing more aggressive chemotherapy, “even though, on some level, they knew that it was unlikely to be helpful,” Granek says.
Meanwhile, some oncologists begin to distance themselves from patients and their families toward the end of life. While patients and families may misinterpret this behavior as a signal that the physician is uncaring, the reality is often just the opposite. “They care very deeply, and the feelings are so intense that their way to cope is to distance,” she says.
Whether to step back is an individual decision, Granek says. While for some physicians, it relieves them of pain they can’t tolerate, for others it can add to feelings of guilt.
Finally, physicians must adopt self-care regimens that proactively help them weather the emotional ups and downs of the profession, Karlekar says. Fundamentally, this means sleeping well, nourishing oneself with good food and engaging in stress-relieving activities.
“I don’t want to preach that everybody has to draw or write or meditate, but you have to find something outside of what you do as a profession that brings you some balance and meaning,” she says.
The key is to use these tools on a regular basis, not just in reaction to difficult emotions. “If you are constantly trying to keep yourself well, even when things get really bad, you’re not going to fall apart,” Karlekar says.
Debra A. Shute is a freelance journalist based in Worcester, Mass. Debra has been writing about healthcare since 2003.
A physician’s psyche can also suffer a dangerous blow when faced with a malpractice suit, says Ilene B. Benator, MD, author of How to Survive a Medical Malpractice Lawsuit. Benator, an emergency physician, was sued twice early in her career. Although one case was dismissed after the deposition and she won the other at trial, she describes the experiences as devastating.
“Doctors go through a lot of hardship to get where they are,” she says. “So when you’re being told that you might not be good, it really hurts you at a core level. It hurts psychologically, and you’re also hurt financially. You second-guess yourself. You worry if you’re going to be employable.”
However, a physician’s state of mind can make or break an effective defense, Benator says. She encourages physicians to seek from their attorneys not just legal advice but help quieting doubts that can sabotage a case. “If you’re a defense attorney in medical malpractice, I would like to think that’s part of your job - to inadvertently do a lot of counseling to get clients ready for trial. They’re probably not going to be good at trial if they’re a mess,” she says.
While other physicians are generally very compassionate to colleagues who have been sued, it’s unadvisable to discuss factual details of an active case, Benator notes. However, she does suggest talking about emotions with professional therapists, if possible. “It’s one venue where you’re allowed to talk about your case without consequence.”
She also found solace in reading online about other physicians’ experiences with malpractice. “Connecting with other people who have gone through it makes you feel less alone in how you cope with it,” she says. Facebook, Twitter and other social media platforms make it easy to find people who have been through similar experiences. “You don’t even have to participate. You can follow a thread and see what everyone else has dealt with. It really puts things into perspective,” Benator says.