Physician Grief

Since the first documented Covid death in the US in February 2020, over 726,000 Americans have died. The number of deaths eclipses the death toll of any other American tragedy, whether war or the Spanish influenza epidemic of 1918, and healthcare providers have been involved with the care of many people who have died. However, grief among physicians over the death of a patient is not something that we routinely address or even acknowledge.

Most people either understand firsthand what it means to lose a family member or close friend or can imagine that aspect of the human experience, and are sympathetic to the grief and sadness that follow. We understand what it is to lose an acquaintance - someone we know, perhaps peripherally or incidentally, but are not deeply connected to. But a physician’s experience of the death of a patient is much less well understood, partly because the relationship between physician and patient is unique - and partly because we tend not to consider the humanity of physicians in their roles as doctors. A patient isn’t a close friend or family member (hopefully), but we often know intimate things about them and their bodies that even the closest people in their lives do not. We are invested in their health and well-being in ways that mere acquaintances are not. And in the setting of Covid hospital care, doctors may know next to nothing about who their patient is as a person, but will have invested tremendous time, energy, thought, compassion, and worry on that person’s behalf. 

Physician grief in response to patient death is poorly studied and poorly understood. A 2014 literature review found only twelve articles that addressed services available to grieving healthcare providers, and explorations of the scope and universality of physician grief have been scarce. I believe that is largely due to physician grief over patient death being disenfranchised. Disenfranchised grief was first described by Ken Doka as grief that follows a loss that isn’t “openly acknowledged… or publicly supported” and the person therefore feels they don’t have the right to grieve or get support. Physicians aren’t supposed to grieve following a patient death because of professionalism. It’s just a part of our jobs, after all. Our medical education specifically trains us to suppress emotional reactions to our work and to power through stressful and traumatic situations. Unfortunately, it doesn’t teach us how to address the emotional reactions afterwards.

Deborah Lathrop argued pre-pandemic that we had a physician workforce already mired in disenfranchised grief from a multitude of losses. I agree. The pandemic has drastically exacerbated the problem, and physicians are suffering. Grief, when not addressed and validated, contributes to depression, burnout, and anxiety, and adds to the trauma some doctors are experiencing. More physicians than ever are burned out, and an astonishing 37% reported they would like to retire in the next year when surveyed in 2020. 

We need to begin to address physician grief by validating it and acknowledging that grief following a patient death can happen and is normal. We can support doctors who grieve the loss of a patient, even one they didn’t know personally. We can offer empathy to each other and give struggling doctors the space to process, vent, and regroup emotionally. Doctors who need extra support should seek counseling with a provider familiar with the challenges of medicine and the impact of disenfranchised grief. We need to remember that physicians are human, and grief is as much a part of the human experience as love. There are ways to support physicians both emotionally and professionally. We just have to make the effort. 

Surviving a Lawsuit

Malpractice claims and disciplinary actions are unfortunate realities for too many physicians. A 2016 survey of physicians revealed that 34% of them had been sued, and 16.8% had been sued more than once. By the time a doctor is 54 years old, there is almost a 50% chance that they will have been sued. Disciplinary actions are fortunately far less common, but a comprehensive review of Illinois physicians’ licensing board data in 2021 showed that 3.2% of Illinois doctors had had a disciplinary action. Current estimates are that 2-8% of physicians will be subjected to some disciplinary action over the course of their careers. 

There are excellent articles and resources that discuss how to survive these events from a practical perspective - don’t discuss details with anyone, look at your practices and procedures to see if you can be more defensive or protective moving forward, etc - but few that discuss the emotional side. The vast majority of physicians experience emotional distress as a result of a claim or disciplinary action. Many report disruptions in their personal and family lives. Given how long and drawn out these processes can be, the distress can last for months or years, and can continue even after a positive resolution or vindication. For some physicians the symptoms are very similar to those of PTSD, with sleep disturbances, anxiety, intrusive thoughts, feelings of detachment, worthlessness, and withdrawal from others. 

When I work with physician clients who are facing malpractice claims or disciplinary action, I start simply with encouraging them to talk about it. Doctors often translate the attorney’s advice not to discuss the details of the case as not discussing the case at all with anyone, but keeping this to yourself is profoundly unhelpful. Silence amplifies feelings of isolation and compounds many of the emotional reactions that doctors in these situations experience. Processing the event or situation with a professional counselor alleviates the isolation; it helps remove some of the shame the person feels; it can help diffuse the intense emotions the person attaches to the situation; and we can begin to identify other areas which might be helpful to explore.The confidentiality protections of counseling help to provide a space for this work that often cannot be found with friends, family, or colleagues. 

Many physicians experience intense shame around malpractice and disciplinary issues. If they are at fault, the shame can revolve around having made an error or struggling with a substance use issue, for example. But even when the claim is unfounded, shame is still very prominent because of the very real fear of being thought of as a bad doctor, or knowing that family, colleagues, or patients might think poorly of you. Doctors tend to be perfectionists, and being accused of making a mistake can feel threatening or excessively vulnerable. Many physicians understandably perceive these claims or investigations as questioning their integrity. Some respond with justified anger. And for many doctors, there is grief - over the loss of autonomy; loss of respect and standing; loss of sense of safety and trust in patients and systems; loss of confidence; and sometimes loss of relationships or positions. All of these reactions are normal and human, but if they are not processed and explored in healthy ways they can lead to prolonged negative emotional and physical effects. 

If the physician is found to be at fault or disciplined, medical directors or licensing boards might require practice changes, supervision, and education. I work with physicians on self-forgiveness and acceptance. I emphasize that to be human is to be imperfect. We find ways to manage their fears of making future mistakes, and work through any guilt or shame. We address any underlying issues, like alcohol abuse or mental illness, that might have contributed to the situation. 

Malpractice claims and disciplinary actions are painful, often extended events that cause suffering for physicians. Emotional support is just as important for quality of life and moving forward as legal support is. I encourage every physician who experiences distress around these issues to seek counseling. 

Burnout & Depression

Last year, a physician friend began experiencing what she believed was burnout. She felt constantly overwhelmed, had difficulty sleeping and eating, and began to dread going into her office. She worried excessively about patient outcomes, decisions she had made, and whether she was actually a good doctor. She even began to cry unpredictably. Like so many physicians who struggle with these kinds of symptoms, she avoided seeking help until she was nearing a crisis with thoughts of suicide. 

The symptoms of burnout are exhaustion, negativism about or mental distance from one’s job, and reduced professional efficacy. While many physicians do have classic burnout, these symptoms are not the only ones some doctors are experiencing when they think they have burnout. Now, consider symptoms of Major Depressive Disorder: depressed mood which manifests as sadness, emptiness, or hopelessness; appetite change; sleep disturbance; feelings of worthlessness; fatigue; difficulty concentrating; and recurrent thoughts of death or suicide.

I did not evaluate my friend clinically, of course, but her symptoms had a lot more in common with depression than with burnout. We already know that half of attending physicians experience burnout at some point in their careers, rates of depression among resident physicians are two to three times that of the general population, and sucide rates among physicians are higher than among non-physicians - with women physicians at higher risk than men. But rates of depression may be even higher than surveys suggest, as misdiagnosis of depression as burnout among doctors may be more prevalent than recognized. 

Despite the high prevalence of burnout, depression, anxiety, and alcohol and substance use disorders among physicians, we infrequently access mental health treatment. Overall stigma around mental health issues impacts doctors as well as the general population, and the mental fortitude and grit encouraged in medicine can make it difficult to admit that we are struggling enough to need help. Busy schedules can make counseling seem like a logistical impossibility even if we are interested. 

The most regrettable reason that physicians do not seek professional help for mental health and drug or alcohol problems is the very real possibility of negative consequences for such a disclosure. Too many physicians have self-reported their depression or alcohol abuse to a department or residency chair only to find themselves facing licensing problems, or reduced responsibilities and restrictions that feel punitive instead of helpful. Some have been ignored or told to just get through it. Other doctors have had their treatment or diagnosis exposed to co-workers or patients, even inadvertently, leading to shame, hopelessness, or a withdrawal from care. Health insurance may cover services only in our own system or we may be unaware that other options are available, so a visit to a mental health provider might mean running into our patients in the waiting room or being treated by a colleague. And since health insurance will only cover counseling services with a mental health diagnosis on record, some doctors have discovered that their recorded mental health diagnosis can impact future life and health insurance policies, and treatment may be discoverable by their employer. 

The disproportionately high number of physicians who struggle with mental health issues represents a crisis in medicine. Unfortunately, the factors that keep physicians from accessing help are long-standing. Wellness programs and efforts to destigmatize mental illness will eventually help, but change is slow. 

In response, some mental health counselors across the country, like myself, have opened private counseling practices specifically for physician clients. These practices have several commonalities - the providers are familiar with the unique concerns of physicians and their careers; they are independent from medical systems that employ physicians; and most are self-pay to eliminate insurance involvement. Some of them even offer more flexible appointment times to accommodate physician’s schedules. Paying out of pocket for counseling offers privacy and confidentiality that is difficult to obtain otherwise. If self-pay is not desired or feasible, or if one of these practices is not available, physicians should consider a mental health provider that operates outside their medical system, or even outside their geographic area. Many insurers, including HMOs, cover some private practice counselors in addition to their in-system providers. 

Finally, attending physicians who are struggling with a mental health issue should consider contacting a counselor first, rather than a department head or employer resource. A counselor can assess the mental health issue, offer treatment recommendations, and provide therapy that meets the physician’s needs - all while protecting that person’s privacy. Mental health providers are legally obligated to maintain confidentiality except under the most narrow of circumstances. Despite the concerns that licensing boards and employers have about risk to patients or impairment, there is little evidence that simply having a mental health issue, or receiving treatment for one, imperils patients. We have abundant evidence, however, that avoidance of treatment imperils physicians. Many physicians have successfully undergone counseling while continuing to work without ever notifying their employer or department, imperiling patient care, or incurring licensing consequences. 

Until changes occur that mitigate the causes of burnout, depression, anxiety, and substance use disorders among physicians, our priority must be increasing access to and engagement in treatment. Physician specialized private counseling practices are one way to accomplish that.