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Good Grief . . .
Arch Fam Med. 2000;9:833-834.
AS I WAS WORKING on this editorial I had the opportunity to reflect on the many occasions in which I have simply sat with my patients. And today would be no exception because during my rounds I was checking up on "Beanie." Her real name is Eileen, but her family and multitude of friends call her "Beanie," the nickname a remnant of a carefree childhood. Beanie has been my patient for 12 years now and we've had many a laugh and tear over this period of time. Probably the most significant event during this period was her newfound independence from her caring family. At the age of 79 years, she took her crippled body and walker to a new apartment in the senior housing tower. Each and every visit I'd hear about the many friends she'd visit, the late nights playing cards, and the comradery that had blossomed among the elderly folks who surely considered themselves family.
On this occasion, I was visiting Beanie in the hospital for her first major medical event, a new stroke. My partner had told me that Beanie wasn't herself, that her affect was flat, and that her previously fluid speech and consciousness weren't there. She was going to need more extensive assistance after this stroke. As I drove to the hospital my attention turned toward concern for Beanie's state of mind. Not being able to return to her wonderful little apartment and be surrounded by friends would be devastating to her. The big smiles and stories about her escapades with the other residents would come to an end. Moving from this home would be a loss for her—a loss of independence, a loss of companionship.
After my visit with Beanie and her family, I thought about where and how it was that we as family physicians learned to deal with the many losses and setbacks that our patients face. Every day I am confronted with a patient whose life will be altered forever, by the loss of a loved one, the loss of independence and function, or the loss of health itself. This was part of the art of medicine I had been told about that was not found in the science texts. Yet I know that we all face loss in our medical practice on a routine basis and have learned to work with it, as if it was a part of the fabric of what we do.
Facing loss is that area in medicine we learn about from personal experience, not from books. We have all experienced it in our patients and sometimes personally in our own families. Earlier this century it was with the hospital chaplain or the country minister with whom the general practitioners developed their expertise in caring for grieving families and individuals. Oftentimes it was the general practitioner and the minister together at the bedside of a dying person who offered comfort in a time when medicine had made few advances. Our experiences with behavioral medicine came from these early beginnings, and not from those of Freud and modern psychiatry. Religious and spiritual enthusiasm were oftentimes viewed as dangerous quackery during the years of secular psychoanalysis. Likewise, at the turn of the century, psychology as a pastoral tool was developed by the liberal Protestant clergy and manifested itself in asylum reform and the notion of compassionate care for the insane.1 It is thus interesting that the strong alliance between family medicine and psychology, rather than psychiatry, came into being. Ministering to the bereaved was probably one of the first common threads between the two disciplines.
The study by Lemkau et al2 in this issue of the ARCHIVES is an important step in the understanding of this art vs the issues of science in medicine. Family physicians have said that they do have a role in helping patients deal with loss. Although there is ample literature about grief and loss, this is the first descriptive article looking at what we do as family physicians in a loss situation. This is the research that needs to be performed to demonstrate the practice of family practice. With renewed interest in palliative care by the public, family physicians will be called on with even greater frequency during times of loss and grief. "Technology" could take a back seat to "touch" in these situations. Preparation for bereavement could replace the "medicalization" of death and loss. It behooves us to discover what it is we do as physicians that works for us and our patients.
This study shows a high level of activity among family physicians in comforting a bereaved patient. The research group describes these active physicians in terms of grief responsiveness. These responsive clinicians act with listening, with touch, or with pharmacotherapy to ameliorate uncomfortable symptoms, and even with attention to spiritual beliefs. The next step into this area of research is to examine the outcomes of this behavior.
As a good research paper should, this study raises a number of important issues that need examination. For example, grief responsiveness occurs when continuity of care exists. Makes sense. Conversely, does the fragmentation of our practices in this managed care environment inhibit grief recognition and care? Are we further compromising health care and wellness in this system by ignoring the common occurrence of loss?3 And how are physicians being compensated for their time, whether in the office or at the bedside, as they tend to the disruptions in their patient's lives? The dreaded V-code is frequently not reimbursable (ie, International Classification of Diseases of Diseases, Ninth Revision [ICD-9]4 code V62.82, uncomplicated bereavement); whereas the commonly used diagnosis ICD-9 code 309.0, brief depressive reaction, fails to describe truthfully the patient's condition.
This study uncovered a high level of bereavement identification activities by physicians. Interestingly, knowledge of a loss through an outside source was the most common situation by which a loss to a patient was identified. The presence of depression or nonspecific physical symptoms also clued the physician into asking about loss. What type of loss the physician identifies as being significant has yet to be studied. I have seen many losses among my patients that resulted in a significant course of grieving. One instance was a divorced middle-aged woman complaining of insomnia and difficulty with memory, who had lost her dog, her close companion; she turned out to be grieving. There are cultural differences in loss that we may or may not recognize as important in the day-to-day care of our patients. As family physicians we are in a unique position to recognize the broad and nontraditional conformations of family and thus subsequent losses.5
Lemkau et al demonstrate that physician self-disclosure is a frequently used tool by the clinician in the management of these patients. This act, intuitive or not, may be the tie that binds the patient and physician closer together. Through disclosure we strive to show empathy and a validation for the hurt and suffering that our patients endure. As physicians we detest suffering. We are taught to end it, to medicate it, to cut it out. This concept of shared suffering has deep spiritual roots. The Dalai Lama speaks often of suffering and has advised, "If you directly comfort your suffering, you will be in a better position to appreciate the depth and nature of the problem. . . . That's why I believe it can be useful to prepare yourself ahead of time by familiarizing yourself with the kinds of suffering you might encounter."6 Wisely, bereavement care is that area in which we can tend to the patient-physician connection outside the transaction of medicine. What do both the physician and patient hunger for, if not for the human connection?
Cynthia G. Olsen, MD
Yellow Springs Family Health Center
1001 Xenia Ave
Yellow Springs, OH 45387
REFERENCES
1. Koenig HG. Handbook of Religion and Mental Health. San Diego, Calif: Academic Press; 1998.
2. Lemkau JP, Mann B, Little D, Whitecar P, Hershberger P, Schumm JA. A questionnaire survey of family practice physicians' perceptions of bereavement care. Arch Fam Med. 2000;9:822-829.
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3. Wolfelt AD. Blessed are those who mourn quickly: managed care and the rapid "resolution" of grief. The Forum. 1997:5.
4. World Health Organization. International Classification of Diseases, Ninth Revision (ICD-9). Geneva, Switzerland: World Health Organization; 1977.
5. Lama Dalai, Cutler HC. The Art of Happiness. New York, NY: Riverhead Books; 1998.
6. Lama Dalai. Cultural variation in lesbian bereavement experiences in Ohio. J Gay Lesbian Med Assoc. Quoted by: Deevey S. 2000;4(1): 9-17.
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