The news of the patient’s death caught me off guard. I had helped transfer him urgently to our hospital two weeks before: He was admitted, treated and discharged with plans for follow-up. I received one short message from his family about a medication adjustment, and then silence. A week later, I heard that he had passed away peacefully in hospice.
My immediate feelings were grief, remorse and regret, followed by a barrage of questions: When had he gone to Hospice? Who had helped his family navigate that change? Had I done enough? Was there something more I could have done? Was his family okay? Were they angry with me that I wasn’t able to cure him? Did he suffer in those last days? I did what seemed natural: I searched online for more information, and found his obituary, published by a loving extended family. There was his picture: at least 30 years younger, but still with the same smile, game for whatever life brought his way. I had met him only in the last months of his life, after he weathered not just one but several cancers. Despite his ailing body, he remained full of joy and hope tempered by patience and perseverance. Clearly revered by family members who remained committed to his care and well-being, he had invested in those around him. I was awed by his ability to maintain this balance against the odds. I admired him as an individual and had been honored to care for him as a physician. The news of his passing saddened me greatly.
But what to do with that sadness? Physicians are not unfamiliar with death: It is ever present, not only as a natural end to the lives we all live, but also because we often are called to be present when death approaches. Physicians deal with grief in different ways. One of my supervising surgical fellows in medical school told me that he remembered the name of every patient who had died on his watch. I remember wondering about the logistics of this: Did he keep an Excel file? Did he commit the names to memory? Around the same time, a news story was circulating about the then-mayor of Braddock, Pa., John Fetterman, who had the dates of homicides that occurred there during his time as mayor tattooed on his arm. The surgical fellow’s admission came in the midst of a conversation where I was being upbraided for missing lab changes for a patient prior to his death: The insinuation was that I had not yet developed an adequate appreciation for the grief that settled on my colleagues following the untimely passing of a patient.
Grief is a topic little discussed between physicians: In the literature, it is inextricably linked to articles about physician burnout and depression.1 It is sometimes discussed as a form of “disenfranchised grief,” a concept introduced in 1989 to describe a type of grief that is not acknowledged by peers in society, inclusive of phenomena such as loss of an ex-spouse, a pet, or a close friend.2 It also is discussed as a form of complicated grief, which is additionally tied to mental health issues.3 The reality is that even robust, healthy, non-depressed physicians experience grief. A Canadian study of practicing oncologists at several different stages in their careers found that the majority of these experience grief that spills over into other areas of life.4 Another small Scottish study of year one physicians showed that 61% of these found their most memorable patient death to be emotionally distressing, and described feelings of grief.5 Grief, however, is all too often complicated by feelings of shame, linked to the ways grieving physicians are perceived as unprofessional or weak.4
But grief in the setting of loss is something that makes us human. Public display of physician grief is rare, but compelling. This was illustrated when the video of an emergency physician crying following the loss of a 19-year-old trauma patient went “viral” in 2015.6 People – patients and their families – want to know that physicians care. It is comforting to know that the physician tasked with the technical aspects of medicine also is doing just that: caring.
How best, then, to express the grief that is a natural part of the physician experience? Losses in this era continue to multiply: the loss of lives due to the pandemic, loss of routine, loss of predictability, loss of livelihood, loss of dignity previously expected from many public officials. Grief can be complicated, but it doesn’t have to be. The processing of grief through mourning offers an opportunity to productively move through loss and continue to maintain the professionalism and energy that is needed to persevere. Mourning is an act of acknowledging sorrow: an external expression of grief that can help us to process loss. This ritualization can help the person experiencing grief to honor and make sacred a normal experience of loss.
The beauty in rituals is that they can take shape according to the needs and desires of the person performing them. In a physician’s busy life, the making of a list, hand-written condolence card, weekly prayer, or some other technique allows that individual to acknowledge loss and incorporate it into his or her personal lived experience of medicine. We tend to focus on the ways denial of grief can be harmful to physician mental health, without equivalent thought about how acknowledgement of its presence can facilitate a healthier and more sustainable practice throughout one’s career. A period of overwhelming loss across so much of our world has pushed me to create private routines to acknowledge loss and properly recognize grief. I encourage those around me to do the same, for the health of our workforce now, and for ensuring that future caregivers have the strength and resilience to acknowledge losses with honor.