Formal training in self-care is relatively uncommon in most medical disciplines. Hospice and Palliative Medicine (HPM) specialty may be the exception. Grief if left unnamed can be a source of great pain, and as with any wound, if ignored, runs the risk of festering only to cause even greater discomfort and distress.
Granek et al published a revealing qualitative study earlier this year establishing patterns of grief responses to patient loss among oncologists as negatively impacting both their personal as well as professional lives1. Some of the impacts included worsened emotional irritability and exhaustion as well as the potential for altered patterns of care for future patients in an effort to shield themselves from further pain. Many study participants described their coping mechanisms as one of distancing and denial. Importantly, participants commented on their awareness of these impacts but had no access to altering their behaviors. In fact, several physicians stated this was the first they had ever spoken openly about these emotions due to the taboo of being unprofessional in the medical community.
Perhaps no different from traditional wound care, exploring the depths of grief, risking heightened pain temporarily in favor of providing optimal exposure, may allow for the greatest potential to heal. By actively creating dialogues with colleagues and openly expressing our feelings of connectedness to our patients and families, this acknowledged closeness and care becomes a natural path to grieving in a supportive environment. In fact, it may provide integrated self-care practices offering enhanced resilience and job satisfaction2.
An opportunity for culture change is at our doorstep. With the recent new policy statements issued from the American Society of Clinical Oncology calling for integrated palliative care from the time of advanced cancer diagnosis, and enhanced doctor-patient communication regarding end-of-life care3, an opening for HPM collaboration offering supportive coping and self-care strategies for oncologists is possible. In the past year at UCSF, a portion of our formal curriculum on self-care in the Division of Palliative Medicine has been piloted within the Medical Residency training program with very favorable feedback. We are now in the process of rolling out a program with the UCSF Division of Hematology and Oncology.
Acknowledging loss can take form in countless ways with varying degrees of time commitment. In addition to creating communal condolence cards for those we have served, the UCSF Division of Palliative Medicine has an annual Day of Remembering where families and clinicians come together and openly share stories of grief and love invariably mixed with tears and laughter. What would be possible if clinicians in all specialties were afforded an environment that embraced relationships with our patients with a natural response of grief at the time of loss? What is more human than acknowledging missing someone we have cared deeply for? Perhaps the promise of remembering our patients is the greatest hope we can offer.
1 Granek, L et al. Arch Intern Med 2012,172(12):964-966
2 Mack JW and Smith, TJ. JCO August 1, 2012 vol. 30 no. 22 2715-2717
3 Smith, T.J. et al. JCO Published online before print February 6, 2012, doi: 10.1200/JCO.2011.38.5161
Dawn M. Gross MD, PhD
University of California, San Francisco
Department of Medicine/Division of Hospital Medicine/Palliative Care Service