# DTD 193
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This is the Drive Time Debrief, episode 193.
Hey guys. Welcome back to the podcast. I'm Amanda. I'm Laura. And I'm Kendra. And last time we touched on some emotions that we're usually not that excited to engage with, including despair and hopelessness. [00:01:00] But today we're gonna continue our talk, talking about sadness and grief. This is important. They live within us.
We're human beings, especially those of us who face loss, suffering, and systemic demands every day. We wanna normalize these feelings, show how they show up in our medicine, our work, our lives and offer ways to recognize and care for them. So going back to one of our feeling specialists, Brené Brown, she says sadness is important and something that we need.
She makes four distinctions. Number one, that sadness and depression are not the same thing. Depression can include sadness, but not always. Sadness is a more transient feeling or mood. Depression is a cluster of symptoms that persist over a period of time. So you know, you have anhedonia, sometimes anorexia, sometimes eating too much, excessive fatigue, little interest in things that you used to appreciate. That's depression. Sadness and grief a lot of times we equate to be the same thing, but technically they're not. [00:02:00] Sadness is one part of grief, but grief includes a whole group of emotions and experiences. Point number three—there are actually positive aspects of sadness.
And Brené quotes Joseph Forgas, an Australian professor of psychology who says, sad people are less prone to judgmental errors. They're more resistant to eyewitness distortions. Sometimes they're more motivated, more sensitive to social norms and act with more generosity.
Naming our sadness is critical in the formation of compassion and empathy. I think it's like reconnecting with your humanity, which then allows you to connect with other humans. I mean, you wouldn't think positive aspects of sadness. When I'm sad, I'm not necessarily like, "Oh, yay, I'm gonna be more generous."
But it's true 'cause you're connecting with your humanity and so it brings out the goodness. Well, I think it's Brené that said this too, like sometimes when you're reflecting on your life, when you were at your lowest moments is when people came in. And that's true—[00:03:00] were there to help. Some of the best moments of humanity can happen in the deepest pits.
I wonder too, this would be something to look into, is when sadness turns into a depression. When it stopped being just sadness and then it's like turned on itself. Like you've lost a connection with that outside of you. This is just me pontificating. Nobody— Well, I'll say as someone who has struggled with depression, you can be depressed and actually not sad.
Depression's more of, in my experience, a neurochemical state where it's like there's a fog on your brain, you have less energy and it can involve sadness, but not always. It's a curious thing. Now, certainly there can be toxic thinking that can definitely make you go down a spiral and make it worse, right?
I'm just fascinated by all the psychedelic research where it's like they have this moment that then fixes it sometimes. Oh yeah, there's progress in that. I use ketamine in the ED pretty frequently for this purpose. Like I had [00:04:00] a teenager a few weeks ago who was depressed, had voiced suicidal ideation earlier in the day and then was like, "No, I do not wanna go inpatient."
And actually had had a sister commit suicide. I was telling his mom, I'm like, "He really needs to go inpatient." She was like, "I think where he could go would make it worse. It made his sister worse." I was like, "Oh my gosh, this is a really hard bind that I am in. Like this kid—" Mm-hmm. He's saying he's not suicidal now, but he's got a flat affect. His sister committed suicide and she said that the place where we could admit him made her worse. I was like, "Well, we could try some ketamine." And so we did. And it's incredible. Like this kid had a completely flat affect when he came in.
We started that. I was like, "It's not gonna be pleasant 'cause it's weird. It doesn't feel great necessarily," but he [00:05:00] perked up, he started smiling and I definitely felt safer letting him go home with his mom. She's like, "I'm not letting him outta my sight. We'll see a psychiatrist tomorrow." So if you're an ER doc listening to this, it's been a really helpful thing for me in those situations where they will not go inpatient, but you're just scared they're gonna do something.
Number four, the reason why we love sad movies is that we like to feel connected. We love to feel moved. It reminds us of our humanity and our connectedness. And I would also offer why we like sad movies is that sometimes I think we convince ourselves that our own sadness is permanent and not fixable.
And we know that the movie is gonna end—it's a brief dose of sadness, but it does reconnect us with our humanity, our connectedness. We can feel what that character is feeling because we've had that same ache. And even if what caused it was different. So we're gonna talk about grief now.
And grief is a process that includes many emotions and [00:06:00] it's not a predictable process that we go through when we have grief. It's not linear. It can wax and wane. Anyone who—we've all experienced grief, I'm sure you know that sometimes you think you're doing fine and then it just kind of hits you.
And research has proven this. There are three foundational elements of grief. The first is loss, and that's death and separation are tangible losses. Noting also that grief is not just loss of a person. It can mean loss of an identity, a loss of a limb, sometimes loss of function. Sometimes we experience loss that's difficult to identify or describe.
The second element is longing. It doesn't have to be a conscious wanting. It's an involuntary yearning for wholeness, for understanding, for meaning. The desire to have that opportunity to touch what we have lost causes that overwhelming ache.
I think about that cry of moms who've lost their child [00:07:00] and just the unspeakable feeling of not being able to hold your living child again. And the third element of grief is feeling lost. It's very disorienting. And when we're going through grief, it requires us to reorient every part of our physical, emotional, and social world.
It can be very, very confusing, disorienting. "How am I going to go on?" It feels like your puzzle has been upended and the pieces are thrown everywhere, and how are you gonna put it all back together again? So grief can manifest in multiple different ways. Acute grief is often characterized by tearfulness, sadness, oftentimes insomnia or possibly hypersomnia as a response to loss, and that typically will last for less than a year.
Anticipatory grief involves feelings of loss experienced prior to the expected loss, especially when someone has a chronic [00:08:00] terminal illness and we anticipate their death. We can definitely be grieving before they even pass. Complicated or prolonged grief manifests as intense and persistent grief that causes problems and interferes with daily life, probably longer than would be expected and I would imagine this would be common, especially in parents who lose children, because you're expecting to have that child in your life the rest of your life. And so where does the loss end? Where is the hole filled? I would imagine it would go on for the rest of your life.
Ambiguous grief refers to loss that doesn't allow for the possibility of closure. So many of us experienced this during the pandemic—seeing so much death, and we don't know the people. We don't have the opportunity to process all of the things that we experienced. I'd say [00:09:00] this is probably true for a lot of the sad things that we may see in the course of our work. Disenfranchised grief involves loss that is not openly acknowledged as legitimate by society and is often accompanied by feelings of shame, guilt, and further isolation. And this, frankly, can contribute to physician burnout.
"Doctors, what do you have to be so sad about? You've got such a great life." And a lot of what we experience just isn't known by people who would say something like that. So just having compassion on ourselves and realizing it is difficult to work where we work. And look for some signs for grief in us.
Some emotional signs would be tearfulness, heaviness, emotional numbness. Cognitive signs are persistent and ruminative thoughts. "I could have done more," difficulty concentrating. Behavioral signs include withdrawal from colleagues, isolating, reduced empathy, [00:10:00] irritability, and many of these can be signs of depression as well, not just grief.
Physical signs include fatigue, insomnia, changes in appetite, somatic complaints, unexplained aches and pains, stomach issues. The clinical spillover comes when we find ourselves overcompensating, doing more than is needed. We might be defensive, we might be hesitant to take on new patients, or one I've seen over and over is fear of taking on complex patients, fear of dealing with tough situations, whether it be resuscitations or traumas, emotional blunting during difficult conversations. And if we find ourselves unable to be able to connect on an emotional level when we're having conversations, that's a sign too. And it may sneak in where you least expect it—in buffer moments, like in car rides, charting, walking to your office.
Suddenly these things might hit you. In your home life, you might find [00:11:00] yourself snapping at loved ones, turning off emotionally, and sometimes in subtle decisions—avoiding, as I mentioned, complex cases, declining to take call that once was really not an issue, and now it somehow seems overwhelming.
Yeah, I think it's pretty sneaky how it can show up and hopefully we've enlightened you as to maybe some awareness if you didn't really understand like, "What am I feeling? What am I going through?" You know, by understanding the different types of grief and the fact that you don't have to lose something tangible to experience grief, it can also be intangible.
There's a few articles that I read in preparing for this podcast episode, which were incredible and just an awareness of how grief and sadness show up in healthcare workers, [00:12:00] how lacking our training is in equipping us with the right tools to cope. But one of these, it was "Hidden in Plain Sight" and really it was a review of 17 articles dealing with professional grief in healthcare setting. So this was physicians, nurses, social workers, anyone in the healthcare worker setting. But some of the patterns that they recognized when they reviewed the 17 studies was overarching that, you know, we are exposed to repeated patient death, but even also bad outcomes could fall into this grief thing because, you know, you were expecting them to make it or maybe you weren't expecting them to do so well. But just the overwhelming grief, the sadness of the story and the patient can really go unrecognized and definitely it doesn't feel supported in the healthcare system.
Many healthcare workers feel unprepared, like I said, to manage this professional grief basically because we don't have any formal training, we don't have bereavement training, we don't have [00:13:00] processing training. Obviously why we're here is 'cause we don't have proper self-care techniques or coping mechanisms, but also that communication with patients that are dying—it's sometimes a very awkward situation. It can really bring in a lot of cultural concerns that we're not comfortable with. So it can be really awkward dealing with not only the patient that's dying right in front of you, but their families. And so that can be something that we avoid 'cause it's just uncomfortable. Healthcare workers frequently experience stronger emotional responses when a patient or family member reminds them of either themselves or maybe a loved one. And I know this has occurred for me in the ED, especially 'cause I had a kiddo that came in that coded at home and he was the same age, blonde hair, blue eyed, like my son at the time.
And that was really tough after dealing with that to not try to really feel that secondary trauma, that vicarious trauma and not experience it as if it was my own. One of the things that really helps improve empathy and patient care is when we identify that this is grief, this is a grief [00:14:00] response, and we'll go into in just a minute how we can name this and allow it. But really improving that empathic response is helpful if we just identify like, "Wow, I'm feeling sad or I'm feeling grief here" and holding some space for it. Some of the healthcare workers described what would help them the best.
This isn't any formal training, but they just, you know, requested paid time off work following difficult cases or difficult deaths. They asked for designated time and space at work to grieve, so maybe a debrief or just a few minutes to step off the floor or go into the break room and regroup.
Structured debriefing, support groups, professional grief counseling—these are all things that were self-reported by these healthcare workers that would improve their experience of grief. One of the things I found was striking was colleagues provided the most meaningful support.
And I think that goes with, you know, what we are as The Whole Physician. I mean, it really takes one to know one. When you're able to sit across the table from someone that's experienced what you experienced and can speak your language or even just hold the space for you, I think that really speaks volumes—[00:15:00] whether they've had formal bereavement or grief counseling or not. Just them sitting across the table from you and just being like, "Hey, I know what you're feeling. I had this same situation, or I've been through this. I feel you." And then, you know, one of the things we preach and we're working on this one small step at a time, it's just a shift in healthcare—the culture away from valuing stoicism and embracing emotional vulnerability and no longer considering yourself to suppress these emotions, but actually call them out in the middle of it happening and then normalizing that this is expected after a situation like that.
And so really, you know, being able to develop strategies around this release of the stoicism—bring back humanity and vulnerability in medicine. Another one by the American Academy of Family Practice, it was called "Good Grief: The Art of Healing Ourselves from Personal and Professional Loss." What I liked about this study was that physicians will carry mounting losses. So if they have a patient death [00:16:00] and they feel that disenfranchised grief from a loss of autonomy or agency, that plus all the other types of grief do mount on top of each other and it's cumulative, and that in itself can lead to that emotional exhaustion and burnout.
And that doesn't go recognized very well because we're finding that, "Oh yeah, you had a patient death," but it was more or less like after a week of having to schedule more patients with less staff and all the things that can feel insurmountable at times and can multiply that feeling of grief—professional grief, inasmuch as it's more non-tangible. So it's that disillusionment with practice.
Another article in the Annals of Family Medicine, it was called "Disenfranchised Grief and Physician Burnout." They spoke about when grief is unsanctioned, meaning not expected—so it wasn't a patient death or grieving from a bad outcome—it may intensify burnout actually, [00:17:00] because it is going to compound, lead to that emotional exhaustion and actually make you more cynical, depersonalize you even. You're depersonalizing, you're losing your humanity. And these are all things that we develop because we just do not feel like we can safely express it. Well, for one, I don't think I was even aware—I don't even think I had the language to express that this was probably professional grief or disenfranchised grief. But also I would've never called it out in my group and at work or anything like that, or even with my partner—and my husband's a physician—but this was just not something we talked about. And so this is one of those subtle ways that really intensifies those feelings of burnout. And no wonder, right? I mean, oh my goodness. So the last one was in JAMA, and it was a meta-analysis of 11 studies with over 21,000 physicians, and those who screened positive for depressive symptoms—so not a clinical diagnosis of major depressive [00:18:00] disorder, just the symptoms—and what we told you before, that sadness and grief and depression can overlap, they don't look the same, they're all different, but they can overlap—it nearly doubled the risk of reporting medical errors. So this is setting us up for just absolute disaster. We didn't even know we were feeling disenfranchised grief or disappointment or whatever. We're burning out and then we have a medical error. Like, guys, no wonder, no wonder we gotta do something.
So what can we do? Well, some of the things that you can do—self-reflection. And we talk about this, getting into the habit of self-reflection is the key to creating awareness and identifying and processing these emotions, especially at their maximal point. So there is a mnemonic called RAIN that I read about in one of this studies. R is recognize.
So recognize what you're experiencing and name it. That's what we talked about. "I feel sad because this is not the way I thought it was gonna be. I feel disillusioned because this is not what I thought my private practice was gonna be." [00:19:00] A is for allow, so you allow or accept whatever you're experiencing. So that means no judgy. You can't judge yourself. You've gotta just sit with it. You say, "I feel sad because this is not what I wanted to happen, but I can sit with this sadness because I'm not gonna try to fix it. I'm not judging myself. I'm not gonna avoid it. I'm just gonna sit with it." We've talked about this before—on average, any emotion that we experience lasts about 90 seconds.
So if you can ride that wave and just sit with it and not judge yourself, not criticize yourself, not avoid it or dismiss it, it's powerful. And then I of RAIN is investigate or be curious why this is happening. So, you know, just asking yourself the question, "I wonder why this sadness is coming up." If it's not obvious—obviously if you just had a bad case, a patient death or a bad outcome, you're gonna be like, "I know why this is coming up."
But if it's that subtle disillusionment or disenfranchised feeling, you might just be like, "What is happening? You know, what are my thoughts right [00:20:00] now? What am I believing? What limiting beliefs am I hanging on to?" These are just some better questions to ask to sit in that curiosity instead of judgment. And then N is for nurture. So this is really the part where you can shut off that character one and two of your left brain and really bring in character three and four, that right brain. This is nurturing your unmet need with compassion. So this is what Dr. Kristin Neff—we talk about this all the time—holding yourself in self-compassion. So either reaching out to one of us—we'd love to sit and talk with you—or a trusted friend or colleague. But also knowing that "What if someone came to me and felt this way? What would I say to them?" and say that to yourself. "It's okay to be sad. I can see why this is happening to you. It's not your fault and you're not alone." So recognizing not only being kind to yourself, but also the common humanity. And so these are all the things that self-compassion theory that Dr. Neff talks about. And so self-compassion, we can embed it in the process above, that RAIN mnemonic.
But it really [00:21:00] helps for us to reframe our thoughts and allows for that emotional healing. Self-compassion activates the parasympathetic nervous system. It decreases our fight or flight, our sympathetic, and therefore it decreases cortisol, decreases stress, decreases heart rate, decreases respiratory rate. All of these things can help improve our sleep, our wellbeing, our positive functioning in the midst of this incredibly stressful situation.
And then there's counseling. It's helpful just to reach out for help. It does not make you less of a person, actually makes you more brave to say, "Hey, I'm feeling this and I need help."
Right. Because we are very much an advocate of offering help, but also advocating for our colleagues to find help before something devastating happens. And then what can we do for each other real quick as we close? Really we can be empathic, right? So we can seek to understand the feelings of others.
This is that sitting across the table from your colleague and being like, "Yeah, this is tough. I'm in this with you." And then there's another [00:22:00] framework for helping with empathy. If you're not like a naturally empathic person and it's a NURSE framework, so you name or mirror the emotion. You say, "It sounds like you might be feeling angry. I hear you." Just reflecting back what they're feeling and then understanding.
And the last is the E for explore. So exploring the emotions further—either telling them like, "Tell me more about this," or even offering like, "Hey, this sounds really heavy and I know you wanna get back to being at the top of your game. Can I offer you, you know, a coach or a therapist or a teacher or whatever?" And then there's other things like meaning-making activities. So there's group coaching, there's group activities. This might be in the bigger scheme of things like a, you know, in the ER if we've experienced a bad outcome or a death, you know, we have a group debrief.
And then connection, connection, connection, connection. We cannot stress this enough. This is not only in that group counseling situation or the group therapy or the group coaching, but also just the one-on-one with your colleague to just really debrief. I mean, especially if it's a difficult [00:23:00] case.
And then Dr. Shona Bhatnagar—I'm not sure if I'm saying that right—but she wrote a whole book called "Grief Healed: A Physician's Guide to Dealing With Grief and Thriving."
And this was amazing. This was out of her own testimony of losing her husband unexpectedly and her son to a chronic illness in a span of 10 months. And she was a full-time practicing physician. So this is an amazing piece, right, from doctor to doctor. So the way she processed it, she's just real in this book.
And then what she did and what was not helpful, what was helpful, and just from the firsthand perspective of being a physician, knowing what we go through, but also experiencing it in her personal life. So next time anguish or grief shows up, instead of pushing it away, how about ask a better question.
"What is this feeling telling me? How can I connect with this experience and actually accept it?" And then "How can I reach out from here?"
You can have times of isolation and sadness where you just wanna be alone. Recognize that [00:24:00] that is not the end, that that's not the final, you know, treatment method or coping mechanism. Community, compassion, courage through counseling, therapy, group coaching—all of these are ways to find a place for this experience, make it have a meaning, and work through it so that you come out on the other side better equipped. And who knows, one day you might be able to reach out to somebody else.
So thank you for joining us today, friends. I know this wasn't a very lighthearted subject, but one that's very, very, very important and we hope that you found this conversation helpful. So please, the best way to show us that you support this and that you are with us is to leave a review. It also helps other physicians find this podcast and moves us up on the list.
So we'd love to hear from you if there's an experience you've had recently or maybe just asking questions about how you can help a colleague. Shoot us an email at [email protected]. And don't forget to follow us on the socials—Insta, Facebook and LinkedIn at The Whole Physician. We love connecting with you there.
[00:25:00] Thanks for spending time with us today. Until next time, you are whole. You are a gift to medicine and the work you do matters.
