Clinician Grief

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Craig (name changed to protect confidentiality) taught me how tough physicians should grieve. They shouldn’t. Craig and I were about the same age, each with sons at similar ages. Craig suffered from advanced lymphoma, no longer responding to chemotherapy. He knew from his shortness of breath and growing disfiguring tumors on his face and chest that he was dying. He asked me to promise, when his time came, to keep him comfortable. I promised.

Late afternoon on a “call day” his nurse paged me to his room. Call days were rough. Each intern typically “worked up” 8-10 newly admitted patients over a 36 hour period and responded to the changing needs of over 100 other patients. Upon entering his room, I knew from his gurgling, irregular breathing and faraway look that he was dying. I remembered my promise as he weakly squeezed my hand. He died a few minutes later.

Aware that I already had two new patients to evaluate, as well as a long list of other tasks, I left the room and headed for the stairs. Alone in the stairwell, I paused — surprised by a single muffled sob rising from my chest. I shook it off and headed to the next admission and, from there, to many more patients waiting to be seen that evening.

The implicit message, “real doctors don’t feel sadness”, I incorporated from those ahead of me in training. One just moves on.

I did not think about Craig again until several years after my internship. I heard the book “House of God,” presented a raucous and hilarious view of internship. Instead of laughing, I wept as I read the book which triggered a flood of memories and bottled up grief. I cried for Craig. I cried for the four year old who was crushed by a car when he darted out into the street, and I cried for his parents, to whom I had to deliver the unfathomable news. My tears felt cleansing as I cried for the many patients who died during my training.

A  study in the Archives of Internal Medicine (Nature and Impact of Grief over Patient Loss on Oncologists Personal and Professional Lives) tracked 20 oncologists for nine months to determine if they felt grief when a patient died and how they coped with the feeling. In a New York Times article about the study, the lead researcher, Leeat Granek, writes that “not only do doctors experience grief, but the professional taboo on the emotion also has negative consequences for the doctors themselves…More than half of our participants reported feelings of failure, self-doubt, sadness and powerlessness as part of their grief experience, and a third talked about feelings of guilt, loss of sleep and crying.”

To avoid being overwhelmed, some physicians and clinicians maintain an emotional distance to cope with a career where they witness so much illness and death. Many clinicians feel they must stay strong for patients and families who are experiencing their own substantial grief. Other clinicians may be reluctant to show emotion in front of patients or their professional colleagues as they perceive this as a sign of weakness.

The study goes on to say “the theme of balancing emotional boundaries captured the tension between growing close enough to care about the patients but remaining distant enough to avoid the pain of the loss when the patient died…patient loss was a unique affective experience that had a smoke like quality. Like smoke, this grief was intangible and invisible. Nonetheless, it was pervasive, sticking to the physicians’ clothes when they went home after work and slipping under the doors between patient rooms.”

Please use comments below to describe how you deal with grief in your professional life.

Fragility

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Years ago, on Christmas Eve, I received a page summoning me to the Hospital Emergency Center to admit a 50 year old woman with flu like illness. On her own power, she walked into the Emergency Center stating she was in excellent health until the past 3 days when she developed weakness and muscle aches. Within minutes of arriving, she seized and never regained consciousness. Blood work revealed kidney failure, low platelets and a peculiar blood smear consistent with rare thrombotic thrombocytopenic purpura. She rapidly deteriorated, developing progressive shock, and died in the Intensive Care Unit within hours of entry into the Emergency Center. As I broke the news to the family, the wails pierced my heart.

I have been on the other side when the wails emanated from my own family.

We in health care are privileged to view life from the perspective of fragility. We inform patients of bad news regarding their terminal illness, support families dealing with the unexpected loss of a loved one, watch as lives instantly change forever, and engage with the courage of other human beings as they deal with loss and grief.

I stand grateful as I witness the fragility of life. I offer thanks for the sacred privilege of working in health care and lessons provided about life, courage and human dignity. Appreciating the fragility of life, I offer thanks for all that is precious in mine.

Use “comments” below to describe lessons you have learned from working in health care.

Healing

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Shirley,  taught me the meaning of “healing” on a Saturday many years ago. On that particular weekend, I drove to the hospital resentful and feeling sorry for myself for being on call and missing family activities.

As her physician for the past few years, I recalled her history as I perused her chart outside the room. I remember her daughter committed suicide earlier in the year. Sometime after the suicide, Shirley underwent a hip replacement complicated by multiple admissions for dislocation of the prosthesis. She had a history of an artificial aortic valve and recently developed acute endocarditis of the valve seeding the prosthetic hip with an infection. During the current admission, the hip was splayed open enabling drainage and antibiotic irrigation of the hip as she received intravenous antibiotics to calm the heart valve infection. Her only chance for survival involved risky replacements of the infected valve and later the hip. I knew I needed to talk with her about the valve replacement. Given her condition, the surgery carried grave risk, but without surgery, she had little chance of leaving the hospital.

As I walked into the room, I saw she was covered with blisters, most likely a reaction to the antibiotics. She whispered one sentence: “I feel like Job.”

I held her hand and cried with her about the events of the last few months. My self­ pity about being on weekend call evaporated. We talked about replacing the valve and the hip and she stated calmly she wanted to live despite her suffering.

Shirley taught me that healing is not the equivalent of cure. Healing occurs when we acknowledge life as it is and exercise personal choices in the face of reality. Healing may occur with the dying process. Healing may result from grieving.

On that Saturday in Shirley’s’ room two human beings healed.

Post script:

Shirley survived the surgery and, after a multi-­month hospitalization, went to a nursing home. After several months of convalescence, she returned home with a full ­time live­ in aide. In the ensuing years, I saw her frequently in the office. Each visit, her courage healed me.

Health care is a sacred opportunity to learn from others struggling to find meaning and exercise choice in the face of suffering. Our work enables each of us to heal as we support the healing of those we serve.

Use “comments” below to describe instances of “healing” while working in health care

Seeing Inside

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In the welcome page to my blog site, I write the following: “moving from youthful illusions of invulnerability to embracing the fullness of loss and love, I realized when I could be still, medicine and leadership brought me back to my starting point- the shared human condition”.

Crabbit Old Woman, an initially anonymous poem later attributed to Phyllis McCormack, paints a poignant image of our shared human condition. I inserted my name, David, where the word “nurse” appears in the original text. This facilitates the old woman speaking directly to me but more importantly it transforms the old woman into me. I encourage you to substitute your name as you read the poem. The poem touches on the person inside each patient; more importantly, it connects us with our shared human condition—the person inside experiencing joy, change and loss.


An Old Lady’s Poem

What do you see, David, what do you see?
What are you thinking when you’re looking at me?
A crabby old woman, not very wise,
Uncertain of habit, with faraway eyes?
Who dribbles her food and makes no reply
When you say in a loud voice, “I do wish you’d try!”
Who seems not to notice the things that you do,
And forever is losing a stocking or shoe…..
Who, resisting or not, lets you do as you will,
With bathing and feeding, the long day to fill….
Is that what you’re thinking? Is that what you see?
Then open your eyes, David; you’re not looking at me.

I’ll tell you who I am as I sit here so still,
As I do at your bidding, as I eat at your will.
I’m a small child of ten …with a father and mother,
Brothers and sisters, who love one another.
A young girl of sixteen, with wings on her feet,
Dreaming that soon now a lover she’ll meet.
A bride soon at twenty — my heart gives a leap,
Remembering the vows that I promised to keep.
At twenty-five now, I have young of my own,
Who need me to guide and a secure happy home.
A woman of thirty, my young now grown fast,
Bound to each other with ties that should last.
At forty, my young sons have grown and are gone,
But my man’s beside me to see I don’t mourn.
At fifty once more, babies play round my knee,
Again we know children, my loved one and me.
Dark days are upon me, my husband is dead;
I look at the future, I shudder with dread.
For my young are all rearing young of their own,
And I think of the years and the love that I’ve known.

I’m now an old woman …and nature is cruel;
‘Tis jest to make old age look like a fool.
The body, it crumbles, grace and vigor depart,
There is now a stone where I once had a heart.
But inside this old carcass a young girl still dwells,
And now and again my battered heart swells.
I remember the joys, I remember the pain,
And I’m loving and living life over again.
I think of the years ….all too few, gone too fast,
And accept the stark fact that nothing can last.

So open your eyes, David, open and see,
…Not a crabby old woman; look closer …see ME!

Use comments below to describe how this poem helps you connect with our shared humanity.

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The Cracked Pot

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The Welcome Page of Between Two Waves of the Sea and the post Wounded Healers describe  caregiver (healer) and patient sharing a universal human wound (uncertainty, change and loss are inevitable; love is a choice). Additionally, they describe our “shared human condition.”

In his book The Dog Says How, Kevin Kling, a local storyteller and playwright, retells the following parable that deepens our understanding of woundedness and our shared human condition:

Back in the days when pots and pans could talk, which indeed they still do, lived a man

And in order to have water, every day he had to walk down the hill and fill two pots and walk them home.

One day it was discovered one of the pots had a crack, and as time went on, the crack widened.

Finally, the pot turned to the man and said, “You know, every day you take me to the river, and by the time you get home, half of the water’s leaked out. Please replace me with a better pot.”

And the man said, “You don’t understand. As you spill, you water the wild flowers by the side of the path.”

And sure enough, on the side of path where the cracked pot was carried, beautiful flowers grew, while the other side was barren.

“I think I’ll keep you, “said the man.

Leonard Cohen paints a similar image in the song Anthem:

“There is a crack, a crack in everything
That’s how the light gets in.”

The parable and the song indicate that beauty, represented by flowers and light, flows from our cracks – our woundedness. All humans carry wounds. Each one of us has our share of unique wounds beginning in childhood, and as we mature we accumulate additional unique wounds. These wounds are left by broken hearts, disappointments, death of loved ones, fears and illness. Additionally, we all share the universal human wound: on the one hand, we are born, we age, we experience loss and eventually we die and on the other hand we don’t want to accept this truth for our loved ones or ourselves.

Empathy and compassion flow like water from the cracked pot as we recognize that every human being nurses unique wounds and we all share the universal wound. Shared humanity emerges from our cracks.

Please use comments below to describe your thoughts about shared humanity and woundedness. Please consider using the share buttons to forward via social media or email to your colleagues and friends.

Ghosts

Over the years, the memories of ten specific patients float like ghosts through my mind. Nurses and other physicians tell me certain faces also haunt them. Recently, I conjured all of these ghosts in order for me to understand what they have in common. The answer surprised me.

The key to understanding the puzzle of why these 10 patients, and not others, haunt me came from two of them, Shirley and Sophie (names changed to protect privacy).

Let’s start with Shirley

Shirley, a 79-year-old patient hospitalized patient taught me the meaning of healing on a Saturday many years ago. On that particular weekend, I drove to the hospital resentful and feeling sorry for myself for being on call and missing family activities.

As her physician for the past few years, I recalled her history as I perused her chart outside the room. I remember her daughter committed suicide earlier in the year. Sometime after the suicide, Shirley underwent a hip replacement complicated by multiple admissions for dislocation of the prosthesis. She had a history of an artificial aortic valve and recently developed acute endocarditis (bacterial infection) of the valve seeding the prosthetic hip with an infection. During the current admission, the hip was splayed open enabling drainage and antibiotic irrigation of the hip as she received intravenous antibiotics to calm the heart valve infection. Her only chance for survival involved risky replacements of the infected valve and later the hip. I knew I needed to talk with her about the valve replacement. Given her condition, the surgery carried grave risk, but without surgery, she had little chance of leaving the hospital.

As I walked into the room, I saw she was covered with blisters, most likely a reaction to the antibiotics. She whispered one phrase: “I feel like Job.”

I held her hand and cried with her about the events of the last few months. My self- pity about being on weekend call evaporated. We talked about replacing the valve and the hip and she stated calmly she wanted to live despite her suffering.

Shirley taught me that healing is not the equivalent of cure. Healing occurs when we acknowledge life as it is and exercise personal choices in the face of reality. Healing may occur with the dying process. Healing may result from grieving.

On that Saturday in Shirley’s room two human beings healed.

I knew Sophie, a friend of my parents, from my childhood. I became her physician when she was quite old and I was in my thirties. During the specific visit that haunts me, I asked what her secret was for aging so gracefully. She said, “David, in order to age gracefully you have to live gracefully.” It was my first glimpse that aging gracefully could not be initiated when you are old. It begins with how you live now.

Shirley made me face my petty crankiness about being on call during a weekend. As I opened myself to her suffering my pettiness evaporated and on that day I became a better human being. Sophie gave me a life map to follow.
Gathering together memories of the ten patients clarified what they have in common. They are not ghosts. They are guides who taught me important life lessons. They made me whole, and thus healed me.

As healers we can heal alongside our patients when we open ourselves to our humanity. By being in touch with our own core human wound of the finiteness of our own lives and the potential loss of loved ones and losses associated with aging, we open ourselves to receiving the gift of healing from our patients as we stand witness to their courage and wisdom facing the same ultimate human wound.

 

Wounded Healers

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Between aging baby boomers, health care reform, genomics, value based purchasing, nanotechnology, “big data,” artificial intelligence, population health, work force retirement and countless technological advances, healthcare promises ever quickening change.

Given the changes, what has not changed? What should never change?.

From the dawn of recorded history we know that human beings long for healing.  The word “healing” implies a return to wholeness. Humans feel a fundamental need to be in harmony with themselves and with their worlds. In response to the deep need, formal healers occur in every culture across the vast expanse of time.

The deep human need for healing-for wholeness and harmony- has not changed. With the certainty of ongoing changes in health care, what should never change is our role within modern medicine as healers.

Carl Jung, a famous early psychoanalyst, described  “archetypes”– constantly recurring themes and symbols in dreams, literature, paintings and mythology. These archetypes, etched in prehistoric cave paintings and embedded in Greek Mythology, appear in disparate and completely separate cultures and today in movies like Star Wars (hero archetype). Jung wrote about the healer as an archetype evident from prehistoric times across dispersed cultures. Interestingly, he called this archetype the “wounded healer“ implying that the archetypical healer needs to be in touch with his/her own woundedness in order to be effective. Thus, the typical initiation of a shaman healer involves the shaman embarking on an internal (and sometimes external) journey to experience and come to terms with their pain- their woundedness.

Jung described the centaur Chiron from Greek mythology as a “wounded healer.“ Chiron became a healer after sustaining an incurable wound from one of Hercule’s arrows. Chiron mentored the orphan Asclepius who became a famous wounded healer. The picture above shows Asclepius with bare chest suggesting vulnerability and carrying a rod with a single serpent. This rod became the “rod of the physician” Thus the rod, as a symbol of medicine, is the wounded healer.

Karolyi Kerenyi, a colleague of Jung, elucidated the wounded healer archetype as the capacity “to be at home in the darkness of suffering and there to find germs of light and recovery…”

Pema Chodron expressed a similar sentiment in “The Places That Scare You: A guide to Fearlessness in Difficult Times,” She writes:

Compassion is not a relationship between the healer and the wounded. It’s a relationship between equals. Only when we know our own darkness well can we be present with the darkness of others.

The “wounded healer“ archetype implies that we need to be in touch with our woundedness in order to effectively support other humans in healing- moving to wholeness. What does it mean to be a wounded healer in modern medicine?

Although we each have our unique wounds, the universal wound is that life is impermanent and changing- we are born, we live and then die. And we have limited control of what happens in our lives. I know I carry a veil over the fragility of life- I can’t constantly face the reality that my life may change in an instant and my loved ones may suddenly suffer and even die. I did not wake up to my woundedness until my mid-thirties when I went through a divorce. Until that time I carried a quiet illusion that somehow I was different from other human beings in that I was fully in charge of my life and magically protected from suffering.  Even though my mother died a few years before my divorce, her death felt like the natural course of life and failed to alter my magical thinking. My divorce, however, shattered the illusion of special protection from suffering. I lifted the veil covering life’s reality and saw with relief I had the same fundamental challenges as all humans- how to make sense and find joy in a world I could not control. After a while I accepted the only thing I could control was the kind of person I chose to be (and even that is not always easy).

I know I became a more effective healer after facing my illusions. I moved from being a doctor who was good at diagnosing and occasionally curing, to a physician who embraced the role of healer. And my practice became more satisfying as I opened myself to the privilege of being healed by my patients as I stood witness to their courage, grace and integrity.

I believe the challenge for modern healers in healthcare is greater than ever. We have the same challenges as healers throughout the ages- to help other humans find some sense of wholeness and harmony in the face of loss and eventual death. But additionally we have the challenge of helping people come to harmony and make decisions based on the scientific model of what is effective.

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