Grief and Oncology: Lessons From a Trainee

Han Cun, MD

I will never forget the first code I witnessed. It was like an orchestrated chaos. Everyone in the room assumed their position as CPR was started and orders were shouted.

At the time, I did not fully understand all the noise: the sound of the chest compressions, ribs cracking, or someone yelling across the room for “epinephrine” or “asystole.” I was merely a premedical student, at home during finals to visit my father, who was hospitalized with pneumonia. I was overwhelmed by the urgency in the room and paralyzed by the vision of my father lying lifeless with an endotracheal tube in place.

As I saw them rolling him off to the intensive care unit, I was overcome with grief—the same personal grief that still follows me today.

As an oncology fellow, I was never taught how to deal with grief, either my own or that which I experience for my patients. In recent years, many academic programs have incorporated curricula on handling end-of-life conversations, but what do those programs teach us on managing the grief that follows?

Oncology is rife with daily emotional stress, something we may or may not have realized when we decided to pursue this field. We observe the roller coaster of emotions that most of our patients and their families encounter throughout their oncologic course. The shock that comes with the initial diagnosis, the hope that endures while receiving treatment, and the relief that comes with remission. Sometimes it is as if the world has been lifted off their delicate shoulders. And if the disease recurs, we are there to witness the oftentimes overwhelming feeling of defeat.

Each day, with each encounter, we experience those peaks and valleys of intense emotion alongside our patients. Without a doubt, these joys and pitfalls have an impact on our mental health as well as oncologists.

Laurel Lyckholm, MD, wrote about this experience in Lancet Oncology many years ago. In his article, "Dealing with stress, burnout, and grief in the practice of oncology," Lyckholm discusses the high prevalence of stress and burnout in our oncologic colleagues, what causes this stress, and also how to prevent it.¹ I agree with most of his techniques, but many are difficult to accomplish as a trainee, particularly: the frequent short breaks, sufficient rest time, regular physical activity, and/or getting 8 hours of sleep each night. Nonetheless, it is essential to learn how to cope with our grief, especially early in our careers to ensure a long career in our practice.

As we prepare ourselves during training, it is just as important to learn the clinical skills that define an excellent oncologist as it is to learn the skills to cope like one. Afterall, how can we manage the daily emotional and psychological trauma over 30 to 50 years of our careers in clinical medicine? How do we build resilience?

As I finish my last year of training, I have grown reflective on the many levels of personal loss I have already experienced. I was just 20 years old when my father passed away, and more recently I lost my husband during fellowship training. These life events have certainly shaped my interactions with my patients and their families, especially during difficult conversations. But more fittingly, these losses have influenced how I manage the stress and grief I experience related to becoming an oncologist. The insight I have gained from these losses include the following:

• Be kind to yourself.

I repeated this phrase to myself after my husband died. It can be difficult during clinical training, but after that loss, I gave myself permission to prioritize myself and my mental health. It was okay to cry. It was okay to feel frustrated. It was okay to take a few extra minutes for myself after having a challenging end-of-life conversation with a patient and their family.

For the first time, I learned to practice compassion for myself, even though for my whole life, I strived to be compassionate towards others. I allowed myself to start journaling, a simple pleasure that provides me some relief from the daily stresses I encounter. However you may approach this mantra, I also urge you to find ways to be kind to yourself.

• Find comfort in community.

After my husband’s death, I was inundated with messages and support from my colleagues and friends. Their compassion helped to fill some of the loss I felt. I recognized how vital those relationships were to my well-being and remembered why I choose to become a physician and oncologist: because of the relationships I hoped to build with my patients. Afterall, no man is an island, as the saying goes. It is community and friendships that profoundly make us human. This support from others ultimately helps us to cope with our daily tragedies.

Previously, my husband was my support person, the confidante I ran to talk about work stress, the trials of training, or challenges with patients. Now, I look to my friends, colleagues, and family members: my new community. I believe we can rely on each other, to ensure we can handle the emotional adversities of oncology.

• Reflect on it.

Whether is is with colleagues or in solitude in my journal, reflecting on my emotions sheds new light to what I am feeling. It allows me to better pinpoint my exact emotions and equips me to communicate my thoughts, my grief, and my desires. After my husband's death, it was therapeutic to reflect and express how I felt.

Additionally, it allowed me to articulate to my friends and community how best they could help me through these challenging times.

Furthermore, sharing these stories and sentiments validates these feelings and helps alleviate the emotional burden felt. Sharing my loss helped me to the face the reality of grief. And although difficult, it was necessary to assist in coping.

Towards the end of last year, one of my patients decided to pursue hospice. We discussed her next steps and how to disclose her decision to her family. Her daughter was away at college, about to start finals. My patient asked if she should have her daughter come home. I reflected back on my own college experience, when I left during my finals week to return home when my father was hospitalized. It was likely one of the best decisions I had ever made: to see my father one last time before he unexpectedly passed away. “She should come home,” I said. “The school will understand.”

Although grief never leaves us, we learn how to cope. And as we become seasoned oncologists, I hope we can not only empathize with our patients, but learn to manage this storm of emotions, so that ultimately, we can touch so many more lives in the future.

Reference

1. Lyckholm L. Dealing with stress, burnout, and grief in the practice of oncology. Lancet Oncol. 2001;2(12):750-755. doi:10.1016/S14702045(01)00590-3