Tuesday, February 5, 2013
Grief is natural, but no one talks about the loss doctors feel when their patients die, according to a qualitative study of 20 Canadian oncologists published in Archives of Internal Medicine.
Because emotion is considered a weakness in medicine, doctors hide their feelings, researchers found. This harms them personally and has negative impacts on patient care.
BLOOM wondered if rehab professionals might have similar emotions when working with families—particularly those whose children acquire disability through trauma. We interviewed study lead Dr. Leeat Granek, a health psychologist who is an assistant professor at Ben Gurion University of the Negev in Israel.
BLOOM: What were the key results of your study?
Leeat Granek: In medical culture, emotion in general is not acceptable. Physicians are supposed to be objective and scientific and to make their decisions based on science. Grief is considered a weakness. There wasn’t much space in oncology for physicians to talk about grief or loss.
In palliative care, nurses and doctors have debriefing and support groups, but there was nothing like that in oncology. Doctors said they would feel uncomfortable talking to another oncologist about their feelings of grief. One of the reasons I wanted to do this study was I thought it was very odd in a specialty so defined by loss that there would be no acknowledgement of it, or grief training, or forums to talk about it.
One thing the doctors did talk about was the focus on cure. Everything they’re trained in, and trying to do, is working towards cure. So when a patient dies, it’s considered a personal and professional failure. It’s the part of the job you don’t want to talk about.
BLOOM: How does the inability to share grief affect doctors?
Leeat Granek: There was a personal spillover. They were more agitated or irritated at home and it affected their quality of life and enjoyment of the job. Impatience, emotional exhaustion and burnout were also talked about.
BLOOM: How does unacknowledged grief affect the way doctors care for patients?
Leeat Granek: One of the things they talked about and felt sadly about was withdrawing from their patients as they got closer to the end of life. A big impact was being reluctant to stay present during the patient’s death, not wanting to walk over to the palliative care unit and see the patient as they got closer to dying. They may have known that patient and family for 20 years. They’re really connected and they know they’re going to feel sad. If you view death as a personal failure and you weren’t able to cure this patient, that’s difficult to deal with.
Withdrawing is a practical and a coping strategy. But one thing physicians really wanted to know was what patients and families wanted from them at end of life, what would be helpful. Institutions and medical schools and hospitals aren’t talking about this. Physicians aren’t talking to other physicians about this. Patients aren’t talking to physicians about this. Everyone is curious about what the other side wants but there’s a lot of silence around the issue. Of course there isn’t one thing that all patients will want, especially in a place like Canada that is culturally diverse.
BLOOM: What kind of supports can bring grief out of the closet for physicians?
Leeat Granek: Acknowledging that this is part of the job, forums in which they can share experiences, having a half day or weekly or biweekly meetings where people get together to talk about patient loss. One thing we found in our study was that oncologists want to meet with other oncologists in the same field rather than meeting with a mixed group of health professionals. They want to talk to others—some more senior and some more junior—and know the other person will understand them.
The other part is vacations, sabbaticals and psychosocial support. These physicians are dealing with chronic patient loss and never get a break from it. They may have as many as four patient losses a week. This is an institutional problem—it’s not the individual physician’s burden to cope with. Hospitals need to set up the structure to support physicians so they don’t get depleted.
I gave four grand rounds at Toronto hospitals and the feedback was that this was the first time anyone had heard anything on the topic. At one of the grand rounds a respected, senior oncologist at the end of the talk jokingly said: ‘Can we make appointments to come and see you?’ Everyone laughed, but that doctor gave
permission for others in the room to start talking and that’s when the discussion opened up.
BLOOM: In children’s rehab we aren’t dealing as often with death, but with congenital disability or disability acquired through trauma or illness. Families go through a grief process. Do you think rehab professionals experience loss they feel the need to push down?
Leeat Granek: I definitely think grief and loss is a part of any medical professional’s work where you’re experiencing these types of incredible losses. If there’s a loss of functioning of who the child was before and the professional is trying to improve the situation and isn’t able to do that, that might lead to grief.
It’s also difficult for parents because there’s still a stigma about grieving in our culture. We’re not very good at it. People are encouraged to move on quickly from losses. If your child has been in an accident, people are supportive up front, telling you it’s going to be okay, you’re going to get rehab, keep going, but then that tapers off. Within a month or two the support disappears and many people don’t want to hear about it. There isn’t a lot of understanding about how loss will continue along the way as this child grows and they’re not doing developmentally what they would have been doing. And most people don’t understand that it’s not about curing loss or grief—it’s about sitting with it.
To live full lives we have to be able to grieve. It’s so simple, but we have such a hard time with it. I often like to say I’m an activist for grief, which is a funny thing to take on, but I believe what I am is an activist for love. They come together. Our ability to acknowledge grief and loss is our ability to experienc the full spectrum of human emotions and to connect with other people. That comes from our vulnerability, not from our places of strength. When we’re not allowed to grieve, it makes things so much harder for people whose child has gone through a trauma or who have a child with a disability.