The loss of a cherished family member is a relatively simple, identifiable moment for each of us when grief, sadness, disbelief, and a host of other mixed emotional reactions surface to become readily recognizable.
I clearly remember my first experience with death as a 12-year-old, when my grandfather passed away from advanced prostate cancer. He was a WWI veteran, wounded during the trench warfare of that era. Like many grandparents in our respective families, he was one of those revered personalities and well-loved by all.
As a 12-year-old, I was quite confused but highly impressed that countless people came to his funeral. I do not, however, remember feeling sadness or other emotions related to grief. My memories are more about my curiosity about death and how people react when someone dies.
For physicians, losing a patient — or many patients during one’s practice time — can create a recurring, collective sense of grief, and this accumulation gradually finds its way into our psyches in a variety of ways. Many physicians attempt to compartmentalize and bury this cumulative sense of loss (or failure as a treating physician), but there is ongoing debate as to whether this approach is beneficial or problematic to one’s overall mental health and well-being.
Over time, each of us ultimately finds a path that seemingly works best for us. The challenge, however, is finding a pattern of coping with this grief that does not inadvertently create long-term negative outcomes.
Recent economic challenges in healthcare, coming off the ongoing impacts of a three-year global pandemic and the profound challenges created for healthcare organizations and the clinical staff within, carry another ripe period of potential grief well beyond the often-discussed industry’s clinical practice or business challenges. Helping to move the industry forward in a positive direction professionally and organizationally while attempting to overcome fresh negative impediments can seem insurmountable for many. When grief is unrecognized, untended, or not allowed to be expressed or constructively channeled, the potential for negative fallout can become manifest in a variety of ways; this outcome is already prevalent.
For example, demonstrated resilience by physicians and other clinical practitioners has been a part of their collective professional skill sets for decades. Setting expectations on the workforce for another higher level of demonstratable but poorly defined resilience may seem unrealistic to those already over-extended or overwhelmed with a cumulative sense of ennui and grief originating from a variety of sources. Facilitating constructive input from physicians to help change industry systems and processes is a better response than stating that increased resilience is a solution.
So rather than continuing to rant about the inadequacies of healthcare, I ask what physician leadership can offer in these times. Quite literally, the answers go well beyond the few paragraphs allotted here, but they do make for robust discussion. Alternatively, how can we better understand our grief as physicians, and how might we convert anguish to an improved receptivity and sense for opportunity and growth?
Understanding Grief and Grieving
Grief is the anguish experienced after significant loss, usually the death of a beloved one, but it may also take the form of regret for something lost, remorse for something done or not done, or sorrow for a mishap to oneself. Grief often includes physiological distress, separation anxiety, confusion, yearning, obsessive dwelling on the past, and apprehension about the future. Intense grief can become life-threatening through disruption of the immune system, self-neglect, and suicidal thoughts. These reactions can also be viewed as abnormal, traumatic, pathologic, or complicated.(1)
A recent personal discovery was Francis Weller’s book The Wild Edge of Sorrow: Rituals of Renewal and the Sacred Work of Grief.(2) This is an intellectual treatise examining grief while also presenting rituals of renewal for better managing grief during our lifetimes. It is not a self-help book, nor does it come across as overly pedantic regarding how everyone should manage grief.
Of particular interest is how the author delineates his premise on the “5 Gates of Grief.” Weller offers numerous case examples while also providing insights into how different forms of ritual might be helpful. I offer my simplistic interpretation of his 5 Gates of Grief:
Everything we love, we will lose. As described above, this is the sorrow we experience with the loss of someone or something we love. Unfortunately, it is typically the only type of grief identified by current popular cultures. The catchphrase itself is an important reminder to us all, and six months of recovery for this type of loss is the norm on average.
The places within that have not known love. The events, behaviors, or emotions each of us has compartmentalized, possibly wrapped in shame, and then banished psychologically to the furthest reaches of our psyche…these neglected pieces of our personal soul ultimately are experienced as a loss within ourselves.
The sorrows of the world. The generalized sense of grief related to the current state of the world’s ecology and the behaviors of its inhabitants often creates a strong sense of ill-defined loss for what is happening to the anima mundi (soul of the world).
What we expected and did not receive. A typically subtle grief related to not experiencing the sense of welcome, engagement, touch, and reflection originating from family, friends, and a community may commence in childhood but then be propagated in an adult, depending on individual circumstances and external influences.
Ancestral grief. The grief carried deep within us is related to the sorrows and trials experienced by our ancestors and our heritage.
Recognizing the constellation of sources for grief and how they find their way to impacting our lives is a critical initial step. Take a moment now to reflect on how the five gates might be affecting your own situation.
Moving forward from this recognition is an equally critical step. Grieving denotes the inner personal, psychic experience of loss and emotional pain. The grief experience comprises individual and collective thoughts, religious discourse, and subjective inner feelings about loss and psychosomatic pain.
In a complementary manner, the outward social and emotional expressions of grief embody the notion of mourning.(3) The expressions include weeping, social and religious performances in dirges and funeral rites, and wistful discourse about a deceased person or entity associated with perceived loss, and ascetic actions. Consequently, mourning is influenced by one’s beliefs, religious practices, and cultural context.
The oft-quoted Kubler-Ross “death and dying” grief model from 50+ years ago was developed for medical student education and was based on a series of clinical interviews with terminally ill patients. The five stages of grief identified were denial, anger, bargaining, depression, and acceptance.
After initial development, it was subsequently reconceptualized in another Kubler-Ross book, On Grief and Grieving,(4) from stages of grief to domains of grief, with the understanding that individuals may move back and forth among the domains without any expectation of a predefined path or progression. However, Stroebe critically reviewed this model(5) in 2017 only to find it actually had limited empirical support.
Grievance is a different but related circumstance whereby one’s thoughts turn to perceiving an unjust or injurious outcome creating grounds for complaint or resentment.(6) This deeper level of grief also can take the form of a complaint or resentment within a formal statement expressed against a real or imagined wrong. In the clinical setting, these could manifest, for example, as patient complaints, medical-legal cases, or staff grievances, including burnout and discontent, submitted to a human resources department.
The Recovery Process
In the mid-’90s, one of the more promising drivers of grief or grievance recovery, beyond a normal period of grieving/mourning, emerged as the concept of post-traumatic growth (PTG): the idea that individuals can learn and draw strength from the adversities that have traumatized them. As understood by the growing field of positive psychology(7) — a discipline that focuses on states of normalcy and happiness rather than mental and emotional dysfunction — PTG is a psychological transformation that follows a stressful encounter. It is a way of finding purpose in pain and looking beyond the struggle (see Figures 1 & 2).
On the individual level, Chowdhury writes,(7) PTG can be recognized by the following positive characteristics:
The embrace of new opportunities — both on the personal and the professional fronts.
A heightened sense of gratitude toward life altogether.
Greater meaning and purpose.
Increased emotional strength and resilience.
Improved personal relationships and increased pleasure derived from being around people we love.
Figure 1. The Outcome Theory of Post- Traumatic Growth
Figure 2. The Model of Life Crisis
Choosing a path toward the benefits of positive psychology and recognizing an avenue to achieve PTG is a deeply personal matter. Francis Weller’s book describes the historical importance of utilizing rituals and how to enable them in a modern world. Alternatively, simply reaching out to better connect and share with loved ones, family members, mentors, peers, or clergy members is often the easiest of initial steps. For others, engaging in individual or group therapy can hold a significant benefit as well.
While the grief may still be there, post-traumatic growth allows a person to look forward in life instead of being stuck in the past. Acceptance and forgiveness of oneself (but not necessarily forgetting) coupled with a personal commitment to move forward in a positive fashion is the optimal outcome.
Seeking ways to help others and the organizations where physician leadership has meaningful influence is the extrapolation of helping create post-traumatic growth for healthcare delivery, given the current industry environment.
Embracing change is always important, and physician leadership has the opportunity to help reshape the evolving business of patient and healthcare. It is indeed an exciting time for creating potentially significant shifts in healthcare through physician leadership. In fact, the number of medical school applicants has increased over the past two years.
Helping Each Other
The medical profession is still viewed as a leadership profession, not only by our industry, but also by general society; therefore, as physician leaders, we must embrace the complexities of our industry, and we can choose to embrace the opportunities where our individual and collective energies can create the positive transformation needed.
Remember, leading and helping create significant positive change is our overall intent as physicians. AAPL focuses on maximizing the potential of physician-led, interprofessional leadership to create personal and organizational transformation that benefits patient outcomes, improves workforce wellness, and refines the delivery of healthcare internationally.
Through this AAPL community, we all can continue to seek deeper levels of professional and personal development and to recognize ways we can each generate constructive influence for one another at all levels. As physician leaders, let us become more engaged, stay engaged, and help others to become engaged. Exploring and creating opportunities for broader levels of positive transformation in healthcare is within our reach — individually and collectively.
References
Grief. APA Dictionary of Psychology. https://www.apa.org/topics/grief
Weller F. The Wild Edge of Sorrow: Rituals of Renewal and the Sacred Work of Grief. Berkeley, CA: North Atlantic Books; 2015.
Mulemi BA. Mourning and Grieving. In: Leeming D. (ed) Encyclopedia of Psychology and Religion. Berlin: Springer; 2017. https://doi.org/10.1007/978-3-642-27771-9_9192-1
Kubler-Ross E, Kessler D. On Grief and Grieving: Finding the Meaning of Grief Through the Five Stages of Loss. New York: Scribner; 2005.
Stroebe M, Schut H, Boerner K. Cautioning Healthcare Professionals: Bereaved Persons Are Misguided Through the Stages of Grief. Omega (Wesport). 2017;74(4):455–473. https://doi.org/10.1177/0030222817691870
Grievance. Collins English Dictionary. https://www.collinsdictionary.com/dictionary/english/grievance
Chowdhruy MR. What Is Post-Traumatic Growth? PositivePsychology.com