I was walking in the store the other day and ran into a recently deceased elderly patient’s relative. As he walked by, I thought to myself, I better stop to say I am sorry. So I shouted to him, “Hey how are you?” He paused, and I continued to walk over and proceeded to offer my condolences. I stated “I am sorry about the death of your loved one. I know how much you cared for and loved him.” As I was saying it my heart was heavy, and I thought of the four other patients who I thought of so fondly and their recent deaths. We continued some small talk and we went our separate ways. As I was driving to the YMCA to get a quick workout in, I thought to myself — who says I am sorry to me or other physicians after patients of ours die? I thought of the four other deaths I faced this past month, a total of five in one month.

I completed my internal medicine-pediatrics residency seven years ago at the University at Buffalo. I really enjoyed my residency and feel it has prepared me well for the vast problems of primary care. However, I don’t think my residency nor any residency can prepare you for the loss of patients that you have cared for and come to know so well.

While the patient mentioned above was in his 90s and the others were in their sixth, seventh and eighth decades, it still hit me hard. Maybe it was the fact that they all died in December, and it is cold and gets dark early in the Northeast. Or maybe it was just the sheer fact that five patient’s whom I thought fondly of died in one month. Perhaps, I am not tough enough.

The point I am trying to make is that neither medical school nor our residencies can prepare us for the loss of patients we have cared for many years. In fact, the current curriculum teaches that grief is considered weak or unprofessional and we should distance ourselves from patients. But how can medical school or residency prepare us? In my case, my residency was four years, and I knew most of these patients for five or more years. So what can we do? Do we disengage and keep from getting to know our patients to avoid the hurt? If we are employed physicians is the responsibility of our employers to have programs in place for our well-being after such situations? Or is the responsibility on us? Do we rely on ourselves to navigate through the grief?

A number of authorities and studies indicate grief reactions among physicians is unknown but that such experiences are fairly commonplace among physicians practicing in the clinical arena. A number of authors have stated the importance of resolving grief responses in an effort to stave off burnout.

Navigating through the grief is tough if we keep it bottled up. After my mother’s passing during my third year of residency, I had to learn to grieve. It was a very difficult time for me. Luckily, I had a supportive program and one pediatric cardiology attending whose mother passed during his residency guide me through the grief and be a guiding light to me. After these five patients passed, I began to feel some of the similar feelings of sadness and loss which I encountered during the death of my mother. However, I was able to recognize that I needed to begin the grief process and find healthy ways to cope. This is what I learned from those experiences. It takes time to learn to cope with the loss, in my case — never seeing my patients walk through the doors again and share some laughter. We can’t get over death, but we learn to cope. Next, each person processes death their own way and on their own time.

Finally, don’t blame yourself or tell yourself you failed. Try to remember the many times you got them through illnesses. During grief we need to rest, relax, trust, hope in the future and have some humor to ward off burnout. I also think that talking with senior physicians who have been through similar losses can be very helpful. Additionally, I spoke with some friends, my staff, my family and I exercised. I also relied on my faith.

So I ask, who says I am sorry? Maybe no one needs to say it, but they just need to be nearby during our times of grief and loss.

Michael A. Mandarano is an internal medicine-pediatrics physician.

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