The grieving doctor has to be given space and time to grieve, both of which are difficult in our current healthcare environment, observe Sai Krishna Tikka, Deyashini Lahiri, and Vikas Bhatia

Among doctors, our satisfaction in helping others and the camaraderie we have with our colleagues are crucial to the care we provide. These two elements allow us to get through difficult times, but the covid-19 pandemic threatens to dismantle these two forms of support.

The covid-19 pandemic has overwhelmed many countries’ healthcare systems, with India particularly hard hit this spring. It poses numerous moral challenges to doctors experiencing the deaths of patients. They have to navigate breaking the news of a patient’s death to family and friends while behind a layer of personal protective equipment or speaking remotely,¹ as well as dealing with the loss of their patients themselves, which is often termed “physician grief.”² 

Doctors lost patients, but they also lost colleagues too. By late June it had been reported that the second wave of the covid-19 pandemic in India had already claimed the lives of about 798 doctors,³ taking the total number of doctors who had died in India due to covid-19 to more than 1500. These deaths don’t just represent a personal loss, they also cause a ripple effect of grief among the doctors and colleagues who worked alongside the individuals. During the prevailing second wave of the covid-19 pandemic in India, where the primary focus has been on “bringing down the curve,” there has barely been the space to notice, let alone acknowledge, a doctor’s grief for a fellow doctor’s death. Before the pandemic there had been reports framing physician grief as “disenfranchised grief”⁴ but we’d argue that this term now fits doctors’ experiences more than ever. 

Disenfranchised grief is defined as “grief that people experience when they incur a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported.”⁵ The three main reasons offered for such disenfranchisement fit with how society may often view a doctor grieving for a fellow doctor’s death. Firstly, grief can be disenfranchised if it centers around an unrecognized relationship. We’d argue that society doesn’t universally recognize the camaraderie between doctors as a relationship that is close and special. Secondly, disenfranchised grief features a death that is a socially undervalued loss. During a pandemic where almost four million lives have been lost, society may count the death of a doctor as just another number. Ongoing narratives during the pandemic about healthcare workers as “heroes on the frontline” may also instil the idea that these deaths are to be expected in their role, with healthcare workers cast as “soldiers” in the “battle” against the virus. Lastly, disenfranchised grief arises when society views a person as an incapable griever. In this instance, society may think that doctors, who are more exposed than most to death and who may have witnessed several deaths in a day during these past months, will be less likely to grieve. 

Given that the characteristics of grief are generally universal, doctors experiencing grief for their fellow doctors will go through the same stages of crisis as any other person. However, two aspects that are specific to our context—the covid-19 pandemic and the disenfranchisement—are likely to complicate their grief.

It’s already been predicted that various factors related to the covid-19 pandemic—the nature of the illness, characteristics of its spread, how it’s overwhelmed healthcare systems, social distancing rules, restrictions on people’s access to day to day facilities, lack of usual mourning rituals, and several other traumatic characteristics—will potentially contribute to complicated or prolonged grief, in general.^{6 7} It has also been suggested that many symptoms that are currently not included in the diagnostic criteria of grief disorders such as “severe forms of traumatic distress, guilt, somatization, regret, anger, and unspecific symptoms” might further complicate it.⁷ Secondly, disenfranchisement is a unique situation that might lead doctors to evade the normal mourning process, internalize grief, and thereby eliminate the supportive influence of external societal sources. The internalized nature of disenfranchised grief paradoxically causes grieving emotions to intensify and complicate.⁵

There are no certainties around how long a person will grieve for,⁸ and there are no formulas or algorithms that can help us reduce the time it takes to heal from a loss.⁹ The grieving doctor has to be given space and time to grieve, both of which are difficult in our current healthcare environment. However, all efforts should be made by hospitals and healthcare institutions to identify those who are grieving, and to provide selective support to them.

Whenever there is loss in the workplace, many non-health corporate organizations arrange prompt individual and collective grief counselling sessions. These are rare in a healthcare setting. However, certain recommendations for clinician wellness during the covid-19 pandemic¹⁰ should still be implemented across healthcare facilities. Individual as well as collective online grief counselling sessions by mental health professionals should be made mandatory. These sessions must include information on basic symptoms of grief that will help people identify themselves as being in grief or other grieving doctors, the universal stages of grief, and various supportive and self-care measures.⁶ 

Additionally, given the distinct disenfranchised nature of doctors’ grief for a fellow doctor, some specific recommendations¹¹ may be useful while providing collective grief counselling: 

1. Resisting the urge to control or condemn the doctor’s grief responses.
2. Acknowledging the importance of the fellow doctor’s loss.
3. Affirming the value of the doctor’s effort towards patient care during the covid-19 pandemic.
4. Encouraging a memorial service in the name of the lost doctor to allow other staff to mourn and recognize their sense of loss.
5. Encouraging staff to create a memory board of lost doctors/healthcare workers to confirm the reality of their experience.

Doctors’ ability to provide patient care in the way they would wish and to enjoy the camaraderie of their colleagues are both affected by their disenfranchised grief for the loss of a fellow doctor. We need to notice, acknowledge, destigmatize, and heal these losses.

Sai Krishna Tikka, associate professor, Department of Psychiatry, All India Institute of Medical Sciences, Bibinagar, Hyderabad Metropolitan Region, Telangana, India.

Deyashini Lahiri, consultant clinical psychologist, Hyderabad, Telangana, India.

Vikas Bhatia, executive director, All India Institute of Medical Sciences, Bibinagar, Hyderabad Metropolitan Region, Telangana, India.

Competing interests: none declared.

References

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3) The Times of India. 798 doctors died during second wave of Covid-19 across country; maximum lost their lives in Delhi: IMA. 30 June 2021. Available at: https://timesofindia.indiatimes.com/india/798-doctors-died-during-second-wave-of-covid-19-across-country-maximum-lost-their-lives-in-delhi-ima/articleshow/83974877.cms 

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