An oncologist must learn how to face the possibility—and very often the reality—of patient loss. For an oncologist-in-training, learning to cope with patient loss is difficult. Feelings of personal grief and sadness may confound the professional responsibility of dealing with terminally ill patients who are facing their own mortality or with families who are grieving the loss of a loved one.

Teresa Gilewski, MD, an oncologist in the Department of Medicine at Memorial Sloan Kettering believes that not enough research has been conducted on the effects of patient loss on the professional caregiver. “It is important to acknowledge that dealing with grief is part of our job, but as a group of professionals there is not enough attention given to this fact. Coping with loss is part of human nature. In this field, you’re going to face death and it’s important to remember that it is normal to grieve,” she said.

In a recent study conducted in Ontario, Canada, researchers asked oncologists what kind of support they would like from their institutions in dealing with personal feelings of loss.1 Training and education were identified as factors that should be provided at the oncology fellowship stage. “While many [oncologists] spoke about receiving education on the grief of patients and their families, few had received any training on how to cope with one’s own losses, either at the trainee stage or anywhere along their career trajectory,” the researchers noted.

Kara Kelly, MD, professor of clinical pediatrics at Columbia University College of Physicians and Surgeons, director of Integrative Therapies Program for Children with Cancer, and director of Leukemia/Lymphoma Program, Division of Pediatric Oncology at NewYork-Presbyterian Hospital/Columbia University Medical Center remembers losing a patient to leukemia when she was a fellow in the early 1990s. “His name was Billy. He was 15 months old. I had experienced patient loss as a resident but as a fellow, there’s a much stronger bond. You’re dealing with much sicker patients and following them over the course of an illness. Being a resident is not as intense,” she said.

Her fellowship did not provide formal training on managing grief, and although she notes that there is still a lack of focus in this area to date, she said that the oncology fellows at Morgan Stanley Children’s Hospital seem to be coping well. “Uniformly, I’m very impressed with these younger doctors in how they support the patient and their families and also how they manage their own feelings afterward,” a fact that may be due, she said, to the type of people drawn into the field or from observing how other oncologists have worked under such extreme settings.

According to the study, mentorship is an important factor in helping oncologists to acknowledge and express their grief.1 It is an approach supported by Dr. Gilewski. “Do not be afraid to initiate a discussion about grief with your attending physician,” she said. “If you don’t acknowledge grief—if you suppress it, it can lead to burnout. We are not super-human.”

According to a 2003 research study, more than 60% of oncologists experience burnout during some stage in their career.2 The authors suggest that it is crucial for oncologists to take time out from work to foster self-care and personal relationships in order to sustain them over the course of what is a very stressful profession.2 Maintaining hobbies and interests outside of the hospital setting, getting regular sleep and exercise, and having a social life also are important to a healthy work–life balance.2

Study results support the creation of structured programs within universities and hospitals to provide a group forum for the expression of shared grief, an avenue that Dr. Gilewski advocates. “We can acknowledge grief privately but it is also helpful to acknowledge it with colleagues. Why do people have funerals and memorial services? It provides some sort of support when you’re grieving together.”

Although regular forums where oncologists can share their experiences with one another may be helpful, some study participants were hesitant about the idea due to fear of being judged for their grief. The culture of medicine, the study found, where feelings of grief may be seen as a sign of weakness, can be a barrier to its acknowledgment.2

“Maybe the culture leans toward suppression of grief, and to a degree that is necessary so that you can function enough to do your job. You cannot allow it to consume you," said Dr. Gilewski, “but it is normal to feel grief. That is the most important message to get across,” she stressed.

Although Dr. Kelly is also an advocate for the creation of structured programs for the expression of grief, she said that programs have to be flexible enough to accommodate different ways of grieving: “We all have our own personal way of dealing with a situation and I think the group has to be carefully created because people may feel like they know how to deal with grief already.”

An area that oncologists seem to overlook as a way of dealing with their own grief is communication with the family in the wake of patient death.3 “Expressing your grief to the patient’s family, for example sending a sympathy card or calling the family, often is helpful to them, but for physicians it’s also a very important part of the process; it allows them to acknowledge their own grief,” Dr. Gilewski said.

Dr. Kelly agreed. “Sometimes we don’t do a good enough job in aftercare for the family. After the child dies, this separation is difficult. I still get a Christmas card every year from Billy’s parents. I’m very touched that they continue to keep in touch with me after all these years.”

“I don’t think it gets any easier,” said Dr. Gilewski. “I grieve as much for patients now as I did when I was a fellow. However, I view being with patients during their time of illness as a privilege. Knowing that you were trying to alleviate their suffering, even if you lose them in the end, helps.”

References

     

  1. Granek L, Mazzotta P, Tozer R, Krzyzanowska M. What do oncologists want? Suggestions from oncologists on how their institutions can support them in dealing with patient loss. Support Care Cancer. 2012 June 20. [Epub ahead of print]   
  2. The psychology of oncology: Physician burnout is going unrecognized. http://www.healio.com/hematology-oncology/practice-management/news/print/hematology-oncology/%7B9DB331E3-5354-4E7F-AD1D-0D1DB8E9AAFD%7D/The-psychology-of-oncology-Physician-burnout-is-going-unrecognized. Accessed August 13, 2012.

     

     
  3. Do oncologists engage in bereavement practices? A survey of the Israeli society of Clinical Oncology and Radiation Therapy (ISCORT.) Oncologist. 2010;15(3):317-326.