Imagine sitting with a trusted colleague in a comfortable, safe environment and being invited to share your grief stories. We all have such stories — likely many — and they may be personal (the loss of a loved one, a relationship, a self-image, or a dream) or professional (the loss of a patient, a job, a role, or an ideal). For many of us, the idea of holding space to process the grief we have been carrying would not be comfortable or familiar, but it is increasingly necessary.

When we entered the field of medicine, little did we know how prevalent grief would be, or the toll it can take — both professionally and personally. Medical education spends little time normalizing grief as part of practicing medicine. The Accreditation Council for Graduate Medical Education's family medicine program requirements include demonstrating competence to “address suffering in all its dimensions for patients and patients' families,” but not for physicians or other members of the care team.¹

Physicians and trainees may, therefore, be unprepared to process their grief and fear being seen as “weak” or “too emotional” if they openly discuss their experiences. Destigmatizing grief and bearing witness to one another's suffering is important for the sustainability of our work. Doing so can help us validate our experiences, feel less isolated, develop empathy, and move forward without burning out.

WHAT IS GRIEF, AND HOW DOES IT SHOW UP?

Grief is the anguish experienced after significant loss, and it often includes physiological distress, separation anxiety, confusion, yearning, obsessive dwelling on the past, and apprehension about the future.² Family physicians experience personal or professional grief almost daily, but we are not always consciously aware of it.

Grief can manifest in multiple ways:

• Acute grief is defined as tearfulness, sadness, and insomnia as a response to loss, and typically lasts for less than a year,³

• Anticipatory grief involves feelings of loss experienced prior to the expected loss,²

• Complicated or prolonged grief manifests as intense and persistent grief that causes problems and interferes with daily life,²

• Ambiguous grief refers to loss that does not allow for the possibility of closure (many of us experienced this during the pandemic),⁴

• Disenfranchised grief involves a loss that is not openly acknowledged as legitimate by society and is often accompanied by feelings of shame, guilt, and further isolation (this can be a contributing factor to physician burnout).^2,3

Increasingly, physicians' professional grief may be related to moral distress or injury. Moral distress refers to “when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action.”⁵ Moral injury refers to “distress that occurs when clinicians are repeatedly expected to make choices that transgress their deeply held commitment to healing. Moral injury locates the source of distress not in individual frailty, but in a conflict-ridden health care system.”⁶ For example, we might grieve the loss of autonomy when our employer pressures us to increase patient volume with less time and fewer staff, the loss of agency when insurance companies deny necessary care or resources, or the loss of personal safety when our organization expects us to work without sufficient personal protective equipment during a pandemic.

Additional reasons for professional grief include disillusionment with practice (“This isn't what I thought it would be” or “This isn't what it used to be”), partner or staff transitions, loss of meaning in the work, feeling threatened by others moving into the primary care clinical space, and patient mistrust. These mounting losses and unprocessed grief can contribute to emotional exhaustion and ultimately burnout.

Many of us are familiar with the five stages of grief — denial, anger, bargaining, depression, and acceptance — which psychiatrist Elisabeth Kübler-Ross introduced in 1969.⁷ Her work marked a shift in how we communicated with patients nearing the end of their lives. In 2004, she and counselor David Kessler proposed that the five stages of grief can also apply to those who have lost a loved one, though the stages are not inherently linear nor all necessary for healthy grieving.⁸ In 2019, Kessler suggested that moving beyond the five stages and finding meaning in our losses can be transformative.⁹

But how do we do that?

WHAT WE CAN DO FOR OURSELVES

None of us are likely in a position where we can immediately change the system to prevent moral injury, professional grief, and loss. But even in a broken system, or perhaps especially in a broken system, we must take steps to heal ourselves. Here are three ways to begin.

1. Self-reflection. Although it sometimes gets dismissed as a “soft skill,” the habit of self-reflection is key to identifying and processing strong emotions so we can move forward effectively. We recommend using a framework such as “RAIN” to guide the process:¹⁰

• Recognize what you are experiencing and name it (e.g., “I feel sad because this is not the way things should be”),
• Allow or accept whatever your experience is, as it is (e.g., “I can sit with the sadness without having to avoid, fix, or judge it”),
• Investigate or be curious as to why this experience is happening (e.g., “Why is this sadness coming up for me now? What has happened? What am I believing?”),
• Nurture your unmet need with the compassion a trusted friend would offer to you (e.g., “It's OK to be sad, it's not your fault, and you are not alone”).

2. Self-compassion. Embedded in the above process, self-compassion can help us reframe our thoughts and allows for emotional healing. It entails being warm and understanding toward ourselves when we suffer, fail, or feel inadequate, rather than ignoring our pain or flagellating ourselves with self-criticism. (See the three-step “Self-compassion break.”) Practicing self-compassion has been shown to be an antidote to feelings of shame and guilt, which often accompany grief. Self-compassion activates the parasympathetic nervous system while decreasing the sympathetic (fight or flight) response by decreasing cortisol levels and heart rate. This can help improve sleep, well-being, and positive functioning in the midst of stressors.¹¹

3. Counseling. This is an important but often underutilized resource that can help physicians navigate the complexities of loss. If grief is causing physical problems and interfering with your daily life, it may be time to see a professional counselor or your personal physician.

WHAT WE CAN DO FOR EACH OTHER

Once we have begun to care for ourselves, we can begin to assist those around us more effectively. Here are three recommended practices.

Empathy. Seeking to understand the feelings of others, instead of shaming or judging them for their feelings, can help normalize grief and promote healing. A useful tool for expressing empathy is the “NURSE” framework:¹²

• Name or mirror the emotion (e.g., “I wonder if you might be feeling sad since that happened” or “It sounds like you might be feeling angry”),
• Understand the emotion and allow for silence (e.g., “I can only imagine what you may be feeling right now”),
• Respect the person and give verbal and nonverbal evidence that their emotional response is important (e.g., “This must be overwhelming to navigate, but you have handled it with grace”),
• Support the person (e.g., “I am here to support you”),
• Explore the emotion further (e.g., “Tell me more about what's worrying you”).

2. Meaning-making activities. Group rituals or activities have long been utilized to process grief and create meaning. Examples include storytelling, artwork or other creative expressions, or annual ceremonies to remember and honor the loss. Meaning-making might also be found through acts of service or supporting a cause connected to the loss. These activities do not restore the loss but can help the group move forward.

3. Connection. Another way to normalize grief conversations for your colleagues and care teams is to offer a formal approach for connection and debriefing, especially for difficult cases. You don't have to reinvent the wheel for this. Consider the following resources:

• The Center to Advance Palliative Care hosts free, informal, peer-facilitated debriefings for members in which participants can share their experiences openly and discuss issues that negatively affect their well-being,
• Balint groups are often embedded in family medicine training programs but can also be used within practices to help the entire care team process complicated emotions, unexpected outcomes, and loss,
• The PeerRxMed program was created by one of the authors (Greenawald) to provide a free, physician-led platform for peer connection, support, and encouragement.
  

MAKING PROGRESS

In 2018, in response to the startling statistics regarding physician burnout,¹³ the American Academy of Family Physicians (AAFP) launched a physician well-being initiative and annual conference to help address this epidemic on multiple levels across the family physician ecosystem.¹⁴ Recognizing the need to develop leaders in this space, the AAFP launched the Leading Physician Well-being Program in 2021 to empower family medicine physicians to advocate for change within their organizations through leadership development, well-being education, and performance-improvement skills.¹⁵ These programs have been influential in helping to disarm burnout, but many physicians have yet to process their professional grief.

Loss is something we all experience. Normalizing our emotions and finding healthy ways to interweave grief practices throughout our lives is paramount. The immense loss we have all experienced in various forms needs to be seen, honored, and moved through. By allowing ourselves to grieve fully through compassion and without judgment, we can find the strength to move forward and give ourselves and those we care for what we all truly need. After all, no one should grieve alone.