Physician Grief: Is integration better than compartmentalization?

originally published August 2018 on Doximity’s Op-(m)ed blog.

Physician Grief: Is integration better than compartmentalization?

An oncologist colleague once said to me at a funeral, “People assume that as oncologists, we understand more about death than other people. But we really don’t.” He then faced a church filled with mourners and delivered a heartrending eulogy. I’ve thought of his words often since. Every time I counsel a patient and family on hospice, or make a bereavement call to a family, I think of his words of wisdom — about our lack of it.

But why? Is it really the best way? Who does it really benefit? Us? The patients?

I recently shared a personal story on not compartmentalizing emotion and grief in this narrative essay published in JAMA. Personal experiences made me think perhaps there’s another way. A different, less rigid way. Maybe, it could be better for our emotional health as physicians not to strive for such hard-line compartmentalization.

How? Our team gathered together — doctors, nurses, support staff, even administrators — and with the guidance of our social workers, shared what we were feeling about recent patient losses. We listened to each other. We cried together. I allowed my team to see a vulnerable side of myself, the one that had been told since medical school never to show herself, or else. But, or else what? Because here’s the thing — nothing bad happened.

Good things happened. Both social workers thanked me afterward for my candor and “being willing to show emotion” in front of the team, because, they said, it gave the rest of the team permission to show their emotions too. Wow, I thought, does that mean before this grief session, my team didn’t think I felt the same things that they did surrounding patient loss? Really?

And because I hadn’t ever spoken to my team about my grief over patient losses before, they assumed I didn’t experience it to the same degree. Kind of made me feel less than human. Which is definitely not the way I want to be perceived by my team. (Or my patients).

From the numerous emails I’ve received since the essay publication, there are lots of us who find this a struggle. (and though I’ve tried to respond to you all individually, I want to give another thank you here to everyone who took a moment out of their busy lives to write to me).

(Please note this is not intended to be an exhaustive review of the subject in a mere 1200–1500 words).

In this 2016 blog post, a pediatric chief resident describes being told by another physician that she had no right to grieve the death of one of her patients. Thankfully she found assistance and was able to work her way through her grief, and concluded:

This lesson, that as a physician, not only am I allowed to mourn but that I am obligated to grieve, is not something I ever found in a textbook or heard in a medical school lecture.” (emphasis added).

In a 2016 paper on how medical students share their emotional experiences, the authors concluded that medical students shared their emotions with other students and family and friends, but not with their mentors or faculty.

[Students] found it difficult to uphold behaviours [sic] that they thought patients, preceptors or the organization expected of them as future doctors.”

Some of us, perhaps not given the resources or tools in our training, end up seeking out help from our palliative care colleagues. In an Art of Oncology essay in The Journal of Clinical Oncology, Dr. Andrea Watson, a pediatric oncologist, writes,

I struggled with grief and sadness. I sought counsel from a seasoned palliative care colleague. ‘It is just so hard,’ I said, defeated. He listened, let me cry, and said, ‘It is hard. Let it be hard — it is rich.’

At one point, I came very close to faking a call I had to take, in order to escape the sadness filling the room, from within and without. Because it would have been so much easier to walk out, to instead put back on the persona of the busy doctor — too busy to grieve — and leave those feelings behind. You are staying, I told myself. This is your team. You will stay. And so — reluctantly, uncomfortably — I did.

And afterward, if some of the team looked at me a little differently because I had cried in front of them, was that a bad thing? Did they see me as less, or, dare I say, more? I was wrung out, drained, like a sponge squeezed dry, but it made me feel more human, not less.

In a personal reflection in the Journal of Palliative Medicine, Patel Leena wondered,

Does crying make you appear out of control and unprofessional? Or does it show that you care?

When she solicited opinions about whether it was ok to cry in front of patients, some told her it was ok, whereas others told her flat-out never to do it because it indicates a lack of control. Nevertheless, she persisted in her interest in palliative care:

They have taught me things that medical school did not. I have learned tears, physical contact, and laughter can have an important role in communicating.

Reinforcing the value of expressing grief as a team, and to cite something outside oncology, this recent paper in the American Journal of Hospice and Palliative Medicine, reported on the benefit of a team ritual in the ICU after patient death, “the sacred pause.” Seventy-nine percent of respondents (a mixture of doctors and nurses) believed that the ritual brought closure and helped them overcome the feelings of disappointment, grief, distress, and failure after the death of their patient in ICU.

If you don’t work in an environment where you could do this as a team, you could do it for yourself. Take a moment for the sacred pause, where you simply allow your feelings to exist. In a call room. In your office. In the elevator. In the car on the way home.

Because emotions are real. And human. And really, what would the alternative be? In an insightful essay, Dr. Patrick Sullivan, a family medicine physician, wrote:

…the normative demands of the profession do not change the presence of emotions for doctors who are inclined to feel them. They just complicate them: emotions have to go somewhere, and so can be delivered or end up, actively or passively, in compartments within a doctor’s psyche. This is how doctors continue calmly and stoically interacting with patients they care about, whom they have just delivered bad news to…

Ideally, doctors would have a moderate emotional response, the appropriate emotional response; they would experience it and move on, unencumbered. This happens. But in some cases it seems the only alternative to some amount of compartmentalizing is not having the emotional responses at all …

And there is a maturation of the emotional responses that happens to doctors over time. Or at least, there is an evolution. … The emotional responses…continue to be compartmentalized throughout doctors’ lives — probably working their way out of their compartments over time, seeping into the doctors’ being, changing them. The goal, I suppose, is feeling the “right” amount for our patients, learning what that amount is over time, being aware of what we are feeling, and letting it go: so we can help our patients in their biology and in their selves, but also remain essentially integrated ourselves.

(emphasis added)

There are only two paths open to those who must witness suffering: (1) pretend it is something else — predictable, resectable, eventually curable, spiritually enhancing, the thing that happens to others, — or (2) see it fully and endure the sequelae of having seen.”

What do you think about compartmentalizing versus integrating? What resources did I miss? Do you or your team have a ritual you use to cope with grief? Please comment.

Originally published at The Hopeful Cancer Doc.

Physician/writer. Essayist, published in NEJM, JAMA, JAMA Oncology, Journal of Clinical Oncology, and The ASCO Post. Doximity Op-Med Fellow.