Formulas for Grief?

Formulas for Grief. Johanna N Riesel, Harvard Plastic Surgery Residency Program, Boston, MA 02115, USA. www.thelancet.com, Vol 393 June 29, 2019. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31421-7/fulltext

After 9 years of surgical training, I know how long a finger can survive if amputated from the body. I know how long you should wait before lifting something heavy after surgery. I can determine how much of a drug you need to treat your infection based solely on your bodyweight. There are algorithms for all of that. But I have no idea how long I am supposed to grieve the dead.Formulas exist throughout medicine to make patient care safer and less subject to human error. Despite these scientific gains, there are complexities to the human catalogue of emotions that we are unable to simplify with mathematical predictions. Scientists have studied grief for years, but missing from all of their publications is an algorithm that allows me to care for myself in the midst of drenching heartbreak while still trying to care for others as a practising surgeon. As of yet, there are no formulas for grief.2 years ago, I lost one of my closest friends. We shared a bond from childhood so strong, I often thought of him as my brother.

After a two-decade-long battle with cancer, after a life-saving bone marrow transplant from his sister, after a double lung transplant, after marrying his incomparable wife, after the birth of their beautiful daughter, Greg passed away. In a memorial held in his honour, I spoke about Greg and the connection we shared to a room of his family and friends. I blamed the tears and choking gasps of air that sliced through my speech on the fact that I had not slept since working a 24-h hospital shift the day before. The next morning, I flew home and went back to work.I did not know how long I was allowed to grieve. As a surgeon, I am not allowed to have a bad day in the operating room, but as a surgical resident, there is an unspoken governance that makes taking time off complicated. Our hospital workflow relies on surgical residents. There is no duplication built into this sys-tem, permitting a balance of hospital productivity and unshared case volume on which graduate medical education relies to train future physicians. Furthermore, the demands of the health-care system are such that taking time off is fraught with conflict and guilt. Patients rely on physicians to heal them, and to do it now, not a couple of months from now. We are drawn to this responsibility and pursue it, despite the costs, quietly enjoying the glorification that comes with sacrifice.

Despite all that we learn in residency, we are not taught to grieve, be it for our loved ones or for our patients. After a severe complication or the death of a patient, many surgeons are lucky to receive even a whisper of empathy from another surgeon. This is not meant to be callous but, rather, functional. For any surgeon, it can feel unbearable to recognise your own grief, old or new, and not look away. Instead, the general counsel is to return to work as soon as possible, a prescription that might paint over the residue of pain from our most difficult cases. Common surgical culture buoys us to “get back on that horse”, and keep our eyes straight ahead, protecting us from the scorch of reliving traumatic experiences. This teaching can spill beyond the walls of the hospital and into our personal lives. In this, it seems we are rarely given the allowance, be it from our mentors or ourselves, to fall apart. Instead, strength, which is often mere stoicism in masquerade, is honoured and instilled.

So, we clench our teeth and swallow the gulp of tears and anguish. We lock our slippery hearts behind the protection of our ribcages. We pour ourselves into the work. After all, work can be a blessing in that way: a distraction from our pain. If you try hard enough, it might let you separate from it completely, all under the feel-good-refrain of doing it for the patients. Eventually, the pain lessens. Or perhaps we are accustomed to it. Our nerve endings once on fire with melancholy now seem desensitised to its presence.In surgery, we are taught that “all bleeding stops eventually”. The body will send proteins and platelets to plug the geyser of blood flow, or, eventually, the body will run out of blood to bleed. I see grieving in medicine the same way. To function and to perform, physicians can plug the leaks in their avenues of emotion, lest they drown us in a flood of heartbreak.

In his years in and out of hospitals, Greg was haunted by the way humanity was chipped from residents and doctors in their pursuit of training and practice. At times, he saw that change in me as well. I struggled to explain my rationale to him. It was never to make myself cold or dissociated from my patients, but rather, to dissociate myself from my own feelings so I could make decisions without the clouded veil of sentiment. Thereafter, I would be left with just the facts, stripped of their human proprietors. If I tried to feel every loss, either of my own or of my patients, I feared that I would bleed out from the volume of cumulative trauma, and never come back to the hospital again. So, I tried to feel none of them.

Few things are more comforting to a surgeon than the control of haemorrhage.But in this fragile state, even the tiniest disturbance can “pop the clot”, yet another dictum of surgery that teaches doctors to tolerate a lower blood pressure so as not to disturb a freshly formed blood clot that had stemmed the tides of bleeding. In states of grief, one image, one word, one memory can disrupt whatever control we thought we had. Suddenly, we bleed. And we bleed for all of the losses we had before but never let ourselves feel. I make it just beyond the threshold of my apartment, and I howl.Greg’s death taught me that I could not tamponade my grief. Regardless of who you are or what you do, you have to step into your grief. It will toss you about and drag you to the ground. It will kick the air from your lungs. But through this tumult, it will take you to a place where, eventually, you can stand again. Ignored emotions will recur until they receive the attention they need. We have to grieve and experience our losses. The challenge remains: when and how?

Although hospitals have policies for bereavement leave, there is no policy for the burden your colleagues will bear covering for you in your absence. There is no policy to dictate the resolution of your own feeling of guilt for abandoning your patients, projects, and partners. Most policies are also written for immediate family members and do not extend to the loss of a dear friend.Or so I thought. When a co-resident died unexpectedly, I found myself engulfed by support from the faculty, administrators, and senior officials at our hospital. Our institution offered sponsored dinners, transportation to attend the funeral, and any time off the residents needed without question. I never knew these resources were not only available but also abundant. Still, I wondered if I had known about them, would I have used them when Greg died? In the middle of a departmental grief counselling session for my co-resident, a colleague stood, turned to walk out of the room, and said, “well, I think that’s enough already. Let’s get back to work”.

I will never know if he was unable to endure the anguish of that moment, or whether he simply thought it was a waste of time. What I did know was why I never felt comfortable asking for time to grieve. I realise now that it will be my choice to follow that example or to set my own.2 years after losing Greg, the grief has lessened. I walk through the hospital not holding my breath in an effort to suffocate tears, but rather thinking of what I need to do next. The grief that once filled my ears with its thunderous roar is barely a din. It is not entirely gone: its stains and stench, like cigarette smoke in a carpet, are evidence of its intransience.

There is a tree dedicated to Greg on his old college campus. Its bark is thick and gnarled, with large cracks that fracture through its trunk like scars mirroring its weathered life. Two of its larger branches have been sawed off. The remaining boughs continue to grow upward, and green leaves sprout above the neighbouring trees, hungry for survival. So much of this tree reminds me of Greg. On a recent trip to visit the tree, I pressed my back into its trunk, trying to imagine that I was leaning against Greg’s shoulder. But the fissures and knots in the bark were sharp and painful, and they pushed me forward as if to say keep moving, don’t stay here. After a moment longer under the tree’s canopy, I walked away, refusing to look back. When I got home, a long drive and a grocery trip later, I stooped forward to unpack my suitcase. A patter of knocks sounded on the hardwood beneath my feet, directing my attention to something that had fallen from my back. A piece of thick, splintered bark from Greg’s tree lay on my bedroom floor.I once heard that the depth of one’s grief is a reflection of the love that was experienced and lost. If that is truth, or even plausible theory, is the formula for grief a symbol of infinity

Despite the adage time heals all wounds, I know the science behind wound healing. The body cannot heal a wound without a scar. Scars are never as strong as the skin they used to be, and they can become thick and raised as if to ward off intruders that might sense their inherent weakness. But scars also show us the lives we have lived. They show us whom we have loved and how they have changed us. After knitting together the shreds of our hearts after a loss or a trauma, they act as the glue that shows the body’s inherent instinct to heal, even when we did not want it to. Science has never found a cure for scars. We cannot make them disappear.So, I kissed that little piece of bark, and I placed it on my dresser, where it sits today. I often forget that it is there until I catch sight of it as I rush to get ready for work in the early morning hours. In the seconds that transpire between sight and recognition, my senses fill with warmth and light. There is a gentle buzz that pushes me forward, a soft thrill from understanding the permanence of love.