Listening to the Grief Stories of Medical Students
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By Johanna Shapiro, PhD
Johanna Shapiro earned her B.A., MA (Counseling Psychology), and PhD (Counseling/Women’s Studies) from Stanford University. She is professor of Family Medicine and founder and director of the Program in Medical Humanities & Arts, University of California Irvine, School of Medicine. In this role, she has developed both required and elective coursework across all four years of medical school. She is the recipient of many teaching awards and an elected member of the Gold Humanism Honor Society. As a psychologist and medical educator, Dr. Shapiro has focused her research and scholarship on the socialization process of medical education, with a special focus on the impact of training on student empathy; professional identity formation; and the medical student-patient relationship, including interactions with "difficult," stigmatized, and culturally diverse patient populations. She routinely uses reflective writing in medical student and resident teaching. She has also presented workshops on reflective writing to family physicians, cancer survivors, and primary care patients. Dr. Shapiro has expertise in patient-centered communication skills, reflection processes, and narrative medicine. She is widely published in the field of medical humanities, and has over 160 peer-reviewed publications.
Dr. Shapiro is a poetry co-editor for the e-magazine Pulse and the journal Families, Systems, and Health; an assistant editor for Family Medicine; and a special medical humanities editor for the Journal for Learning through the Arts. Her book, The Inner World of Medical Students: Listening to Their Voices in Poetry, is a critical analysis of important themes in the socialization process of medical students as expressed through their creative writing. In her spare time, Dr. Shapiro enjoys spending time with her 5 grandchildren, playing folk guitar, writing poetry, and taking walks on the beach.
At the beginning of the coronavirus pandemic, a colleague sent me an article in the Wall Street Journal (which I do not normally read). Its title was “That Discomfort You’re Feeling is Grief”. When I read it, everything fell into place for me. As a psychologist, I was well aware of many feelings I was experiencing – fear, anger, helplessness, anxiety, stress. But in all this mish-mash of emotion, I’d missed perhaps the most significant – grief.
Having spent decades honored to receive stories of medical students about their lives and experiences at the University of California Irvine, School of Medicine, I’ve come to the conclusion that, like me, students often miss their own grief. Other emotions seem easier to acknowledge – stress resulting from the burdens of constant studying, examinations, and evaluations; moral outrage and righteous anger at institutional and societal injustices; anxiety and depression arising from “imposter syndrome,” the sense that one doesn’t belong, isn’t good enough to be in medical school. But how does grief factor in?
Over the years, I’ve realized that, sadly, there are many kinds of loss (with resultant grief) that medical students may experience while they are also experiencing medical school. Most serious, of course, are actual deaths of grandparents, parents, relatives or friends. Students facing these situations may feel conflicted about taking time to return home to be with family, or even taking a leave of absence to deal with their loss. One of the stories I heard 1 was from a student who decided not to sit shiva2 for his grandmother on the other side of the country so he could take a major exam in physiology. Although there is no obligatory religious requirement for grandchildren to mourn a deceased grandparent in this way, the student felt terribly guilty about his choice, and admitted he felt pressured to place his profession above his family.
Other students have experienced confusion when family members thrust them into the “doctor” role, although some may barely have completed their anatomy course or have only rudimentary clinical exposure. On the one hand, they are proud to help frightened and confused loved ones navigate the complexities of the medical system; yet in assuming this responsibility, they may lose the opportunity to be just a daughter or a grandson themselves. One student described her experience as being reduced to an “intermediary” between her father’s doctors and worried relatives.
Death for medical students is not only personal but professional. Once they reach the wards, death surrounds them, sometimes as background noise, sometimes in profoundly intimate ways. Students often endure distress when a patient dies, especially when it is their first death or when they had a close relationship with the patient. A typical story that I’ve heard repeated in one variation or another was from a student who, at the bedside of a dying patient with whom she’d made a connection, was told by a resident not to cry because “it made everyone uncomfortable.”
Students experience other losses as well. Sometimes they feel disconnected from family and friends because of the pressures of medical school. They worry that academic demands make it difficult to stay in touch. More seriously, they worry that the unique experiences they undergo as medical students – dissection in the anatomy lab; encountering death and dying on a regular basis – mean that others outside medicine no longer truly understand them. One student shared that she used to be very close to her mother. Yet when she talked with her mom her reactions to donor dissection, including the smell of formalin in her clothes, skin, and hair and the globules of fat sticking to her shoes, her mom tried to comfort by saying rather helplessly, “It’ll be over soon.” The student ended up feeling that only her classmates could viscerally grasp what she was trying to express.
One of students’ most significant forfeitures is the sense that, in order to become physicians, they must give up aspects of themselves. They often conclude that the requirements of medical professionalism force them to submerge or smother essential elements of their own identities, what makes them uniquely themselves. They lose touch with hobbies, pleasurable pursuits, and even just leisure time to sit and be. A story illustrating this harm involved a medical student who was a classically trained pianist and had won several competitions, but since entering medical school had not played her instrument once. She mourned the sacrifice of a significant source of meaning in her life, and felt she was no longer true to herself.
Finally, students routinely experience a diminution of idealism, particularly in the clinical years, when they discover that the world of medicine all too frequently mirrors the economic disparities, racial injustices, anti-Blackness, misogyny, xenophobia, and implicit and explicit biases of the larger society. I have been the recipient of heartbreaking and infuriating stories in which medical students discover that they cannot always deliver the kind of care they know a patient deserves; and that patients, attending physicians and residents do not always treat them as whole persons. One medical student recounted how the husband of an OB/GYN patient stormed out of the room with his wife in tow when he realized that her obstetrician was African-American. In consequence, students learn to repress aspects of their “voice” that others have judged to be unprofessional, to remain quiet when they see wrongdoing.
In the face of loss, medical students sometimes feel that it is not okay for them to grieve. They offer several insights into this impression that grieving is incompatible with being a good doctor. Unless the loss is an actual death, students may be concerned that their feelings of grief are trivial, not worth “indulging.” Students see so much “real” suffering on the wards and in the clinics that they have a tendency to minimize their own losses as insignificant, thus depriving themselves of the possibility of grieving those wounds. Even a death may result in ambivalent feelings. Grieving is a painful process, and it is easy to take refuge in the medicalization of loss, to focus on the what of the patient’s or even their loved one’s condition, rather than permitting themselves human feelings. In this way, students may postpone or completely avoid necessary grief-work. Students further fear that grief is a sign of weakness, in a profession that seems to require a consistent show of outward strength. This leads them to dissemble and pretend their grief does not exist, or to express their grief alone, in isolation.
What can we, as medical educators, do in response to student grief? First, and most obviously, we can acknowledge grief for the very human and healthy response to loss that it is. We can be explicit in reassuring medical students that grief is normal, natural, and a process to be respected. Secondly, we must be careful not to pathologize grief by simply “handing off” the student to a mental health professional. Students may well need expert support and even psychological or psychiatric intervention at times; but we should not be afraid to simply be present for students as a way of normalizing the telling of grief stories; and when appropriate, to mourn with them. Third, if the timing is right, we can help students understand that the grief they inevitably encounter in their personal and professional lives can be tolerated, even welcomed; and that grief, like all of life, can offer valuable insight and meaning that has the potential to make us more empathic and compassionate toward others and to be of greater service.
As the coronavirus established a foothold in our country, I started to grieve. I grieved the deaths that multiply unabated, and the inequitable nature of those deaths that reflects the endemic racism of this country. I grieved the suffering and long-term harm so many patients are experiencing. I grieved the lack of protection for our essential personnel and healthcare workers. I grieved losing face-to-face contact with students and colleagues and especially with my beloved children and grandkids. And, like everyone, I kept going.
With grit and grace, grief that is not stifled and suppressed will usually run its course in a natural human cycle. We emerge from loss not so much having “moved past” our bereavement as “moving with” it. When medical students learn not to fear or avoid grief, not to worry that it makes them less-than as doctors, in fact they will become better doctors because of it, and better people too.
1 Details have been altered to ensure the privacy and confidentiality of students
2 7 day period of Jewish ritual mourning