I woke up today wearing the lead suit of grief. I was tired, irritable, and tearful.  I was angry at the lack of PPE and the risk that this poses to my colleagues.  I was sad, anticipating the loss of my colleagues who are still alive and well.  I was in denial, wondering if I could sneak my kids out of town for spring break.  But in reality, I was grieving.

Anticipatory grief is the feeling we get when the future feels uncertain, usually centering on worry about death. It’s the feeling that there is a storm coming. It’s the anticipation of loss.  In the COVID-19 pandemic, for me, this anticipatory grief centers around the loss of my colleagues, patients, and loved ones.

My grief was precipitated by recognizing that my colleagues who have dedicated their lives to caring for patients will die.  The sacrifice of health care workers doesn’t seem fair, and yet the sacrifice is made willingly.  I am worried about my colleagues. I am worried about their lives and their mental health.  This loss of purpose-driven lives is where anticipatory grief is the heaviest for me.

Elizabeth Kubler-Ross’s five stages of grief have manifested in me as:

• Denial. This virus has not made it to my city.
• Anger. COVID-19 is here! Where are the leaders? How are we supposed to care for patients without PPE?
• Bargaining. If I just get through the next few weeks of work (while homeschooling my children), everything should be fine, right?
• Sadness. People I know are dying.
• Acceptance. This is happening.  I can play my part in crisis relief.

It is in acceptance that we transform our grief into action:  I can wash my hands to stay safe.  I can develop protocols to protect our teams in the hospital.  I can live in the basement to protect my family.  I can care for my patients via telemedicine.  I can train to work in the hospital.  I can discuss my advanced directives with my family to prepare them and myself for the reality of practicing medicine in this pandemic.

Physicians are “doers.” We are trained to respond, intervene, and act.  Hospitals are now full of COVID-19 patients who emergently need care.  Action is needed immediately to save lives in this pandemic.  However, we are well trained to compartmentalize our emotional response, and with significant loss, it can be weeks, months, or years until we are able to process our experiences.

The moral injury of caring for patients during this pandemic cannot be understated.  We will soon run out of ventilators, hospital beds, and clinicians to treat sick patients.  In the March 23, 2020, NEJM article, “Fair Allocation of Scarce Medical Resources in the Time of COVID-19,” authors present the ethics and their recommendations about care in the setting of scarce resources, specifically surrounding ventilator allocation. “Undoubtedly, withdrawing ventilators or ICU support from patients who arrived earlier to save those with better prognosis will be extremely psychologically traumatic for clinicians (2).” Yes, it will be.

In addition, we are already unable to deliver much-needed care to our non-COVID patients.  Elective surgeries and procedures are canceled.  Chemotherapy is delayed.  Immune suppression is avoided, flaring chronic illness.  Medications are unavailable due to fear-driven hoarding.  The inability to care for our patients is traumatizing.

The irony of this crisis is that while teams in the hospital are stretched thin, some outpatient practices may not survive.  By protecting healthy patients and insisting that they shelter in place at home, some outpatient practices cannot pay their staff and keep their doors open without the daily influx of patients.

Physicians will lose their lives and livelihood by caring for patients in and out of the hospital.  We cannot pretend that we will survive this pandemic unscathed by trauma and grief.

We will need space to process our experiences.  Studies have shown that physicians lean on physicians during times of crisis because we uniquely understand the mental, emotional, and ethical load that we willingly carry.  There has never been a time that we need each other more than now. If we are ever to find meaning (David Kessler’s sixth stage of grief) in this pandemic, we will need each other’s support for years to come.

Kara Pepper is an internal medicine physician and can be reached at her self-titled site, Physician Life Coach: Kara Pepper, MD.

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