Behind those scrubs

Zipping from one room to the next
From tragic to devastating
My scrubs reminding me that
Their sorrow is not supposed to be
Mine.

Speaking with one family to the next
From devastated to desperate
Their tears reminding me that
My sorrow is nothing compared to
Theirs.

And yet I cannot deny
That under the same stars and sky
Our sorrowful tears drench my scrubs
And once again I feel
Human.

Witnessing final goodbyes and confessions of regret are part of the daily grind in palliative medicine. Even the bittersweet proclamations of love and gratitude can find their way into your 'trained' heart. Don't forget the fiercely protective families pleading for another miracle, praying for their loved ones to fight just one more battle (and win!).

If getting scrapes and bruises are part of a mountaineer's job, then grieving is the equivalent for a palliative care physician. Yes, I am saying we, clinicians, grieve. Even those trained to tread these terrains.

Is grieving even allowed as a clinician? As far as I can remember, the Ethics and  Professionalism module in my medical school taught me that setting professional boundaries ensured an uncomplicated therapeutic relationship. Even during my specialist training, I was told that if I was grieving, it meant I went too far. I recall a mentor telling me 'we have no right to grieve, who are we to do so? We are not their family'.

For this reason, I have always felt ashamed to acknowledge my grief, for fear of being deemed unprofessional by the fraternity. Surely there is wisdom in setting professional boundaries. Setting professional boundaries: if only it was as simple as it sounds.

Another equally yet conflicting ethos of palliative medicine is to 'meet the person where they are'. I recall a 19 year old patient who, in her lonely struggle to find meaning to her short life, asked if I would be sad when she died (and she asked inspite of severe dyspnoea). To which, I responded instinctively, 'of course I will!'. She took it further and asked if I would accept her Facebook friend request. Which begs the question, what if 'meeting them where they are' requires you to rethink your professional boundaries. What if that puts you at risk of clinician grief?

I didn't set professional boundaries that day. I took my phone out, opened my Facebook app, and accepted her friend request. She smiled and said, 'we are friends now!’. The next day, she died. During mortality rounds, as if to confess a sin, I shared with the same mentor that I had accepted her friend request. To which, my mentor commended me for giving her the gift of friendship. Professional boundaries... not so straight-forward. Clinician grief, hard to avoid when we are caring for people.

I am not alone. I witness clinician grief in other healthcare professionals too. It is only in the recent years that I have started to recognise this. How many times it has gone unnoticed and worst still, misinterpreted as bravado. Whether it is the surgeon who has gone in for the fourth salvage operation in 2 weeks to fix a complication and is at odds with the ICU team for limiting the extent of care (in addition - horrors of horrors - calling in Pall med), or the oncologist who can no longer offer further chemo but leaves that decision hanging in order to delay the final declaration of the last chapter.

Over time, and having cared for many who have challenged my professional boundaries, I have discovered that clinician grief is unavoidable, and it doesn't mean you are unprofessional. Ironically, denying one's natural response to grieve or acting in a way to avoid grief causes cognitive dissonance and may even lead to burnout (Sansone et als).

It is much more useful spending all that energy to learn how to manage one's own grief than to avoid or deny it. How do we do it? Just ask yourself how you would respond to someone who is grieving. I now approach grief, in others and for myself, with more care and compassion.

Professional boundaries are important as they keep you safe for the most part as a doctor. But if you encounter moments where you have to choose between professionalism or being human, I hope you choose to be human.

Jamie is a palliative care physician who believes she has the best job in the world — her work entails listening to untold stories of extraordinary lives. While this can be heavy and intense, poetry is her way of channeling these special encounters to better understand our common humanity. More of her work can be found here.