In a Zoom breakout room a few months ago, I watched the face of a fellow group member fall as he talked about his reason for participating in a grassroots vaccination campaign effort.
We were supposed to be explaining our “whys” for being there ― usually a motivating and uplifting assignment. However, this colleague had lost a dear patient to COVID-19 that day, and his unprocessed grief, although subtle, changed the tone of the room.
“It sounds like you’re processing a loss, do you want to talk about it?” I asked my colleague.
He looked surprised and seemed to oscillate between his need to preserve his identity as a composed physician and his need to process an emotional burden. While we didn’t have enough time in the breakout room to talk in depth about his experience, I offered to listen if he needed it and encouraged him to schedule time to grieve.
My own experience with grief during the pandemic was unexpected and overwhelming, and I wish a physician colleague had named what I had gone through earlier in the process. In the two months after my experience with vicarious grief, I shared my story with whomever would listen. The unrestrained storytelling, I realized later, was a healing process, and I found that sharing my grief actually opened up conversation for others to share their grief as well.
During these grief conversations, I learned what it was like to be a neurologist assigned to be an inpatient COVID attending; how hearing codes every five minutes in a Bronx hospital made it seem as though the Grim Reaper was randomly pointing at patients while roaming the halls. I learned how a large bedazzled sombrero, gifted by a patient who passed from COVID-19, was cherished by the geriatrician who lost dozens of patients this past year. I also learned about anger, feelings of betrayal, exhaustion and resentment of policies that seemed to ignore the burden clinicians shouldered to keep people safe and alive.
Within the literature, interest in studying physician grief appears to be limited. A quick PubMed search of the term “physician grief” results in an extensive collection of articles on how physicians can help their patients through the grieving process. Only a handful of studies examine how grief (and the more clinically concerning “complicated grief”) affects physicians. Few studies describe interventions to prevent negative outcomes.
During my search, I also found essays by a number of physicians who felt shame for grieving, either due to their own discomfort with grief or as a result of overt dismissal by colleagues. Additionally, I was intrigued by the concept of “disenfranchised grief,” or grief that is considered socially unacceptable, such as grief over changing practice models or, in the case of the pandemic, grief over the expectation to care for patients regardless of self-preservation or safety concerns. The invisibility of this type of grief lends itself to complicated grief and shame.
Grief and loss are unofficial curricula of medical training ― omnipresent but largely unacknowledged. Because they are unofficial, medical trainees graduate with inconsistent coping strategies and skills. If you’re like me, you once had (or maybe still have) maladaptive responses. In residency, for example, I avoided a patient who had experienced the sudden and harrowing loss of stillbirth for weeks, only to realize that courageously showing up for the patient was part of my role as her physician. I still remember the first patient who died under my care, the first death certificate I signed, and the first midnight conversation I had with a patient’s family in the ICU waiting room, where they thanked me for caring as their loved one passed away.
There’s also a chance that, like me, you’ve rarely acknowledged how much grief you absorb in a given day. There is the sullen acceptance of a patient who needs to start a new medication, or worse, the grief of realizing a treatment doesn’t work. It can extend to more obvious grief, like when patients cry, or more subtle and resigned grief, like a patient’s acceptance of a chronic condition.
A 2012 qualitative study in which researchers interviewed 10 family physicians caring for women with substance use disorder found that the “narratives of loss, grief, and compassion were consistent with vicarious trauma, and therefore participants risked developing compassion fatigue (a risk factor for burnout).” The helpful coping strategies identified in this small qualitative study included learning to bear witness instead of trying to fix things, modifying expectations given the real-life challenges that patients face and, most importantly, teamwork, which was defined as blocked time to discuss patient care and collaborate with colleagues who have shared experiences.
That last strategy is key.
In one of the only comprehensive published studies on interventions for physician grief, psychiatrist Randy Sansone, M.D., and family physician Lori Sansone, M.D., aggregated recommendations for managing physician grief, the first of which was to have “death talks,” or “social engagements that examine the complex dynamic of grief.” Additionally, professional grief support, didactics on grief, personal awareness, writing clinical obituaries in honor of patients lost and the incorporation of humor were all suggestions outlined in the literature to address grief.
The reality is that physician grief, while ubiquitous, is still something we navigate mostly on our own ― especially in the context of an isolating global pandemic. Losses have been compounded over the course of a year, team meetings and other protected time with colleagues deferred, and chance moments of connection with co-workers lost amid the day-to-day of masks, gowns, physical distancing, and telemedicine.
In a year full of grief, I’ve therefore chosen to slow down and lean into the experience of grief, as well as the anger, shame, denial, bargaining and depression associated with it. In moments where I identify grief in myself and others, I try to acknowledge it out loud, partly as a mental note for me: Oh, this is grief. If team meetings are not possible at work, I’ve tried to create forums and discussion groups around grief with friends and colleagues (admittedly with varying success).
Perhaps reassuringly, I’ve learned that when people finally admit their grief and tell their story, the initial response ― although challenging, uncomfortable and sad ― ultimately gives way to lightness, smiles and even laughter. Laughter leads to bonding, a release of expectations and, paradoxically, more clarity and conviction.
So, physicians, acknowledge your grief, talk about it, and remove the burden of compartmentalizing it. There is beauty, joy and connection on the other side.
Lalita Abhyankar, M.D., M.H.S., is a family physician practicing in New York City. You can follow her on Twitter @L_Abhyankar.