Patients die. This is a tragic truism in the world of medicine. Usually, the patients who die are elderly. Patients die from diabetes and kidney disease, or from alcohol abuse and liver failure, or from heavy smoking and lung disease. Or patients die from cancer.

As a physician, I take these deaths in stride. I try to provide comfort care as they lay dying. Patients often pass into a dreamlike state, at the end. They are not fully conscious. I provide morphine for any pain, which may or may not hasten their entry into the final, dreamlike state.

However, it is the deaths of patients who are too young that tear me apart. Instead, it is the deaths of patients I thought I could save that keep me awake at night.

I talk about this to a friend who was a psychiatrist. I lose a patient, but I am not sure if I have made a mistake somehow. The psychiatrist, who is in his late 70s, reproaches me.

“Do you think you are such an excellent doctor that no patients of your will die?” he asks. “That you never make mistakes? And the rest of us, whose patients do die, who do make mistakes – are lesser doctors than you?”

I feel stunned. Isn’t he supposed to comfort me? Isn’t he supposed to tell me I had done the best I could? Instead, he chastises me for thinking I am better than other physicians. It takes me a few days to realize that what he says is helpful. He tells me I am a member of the brotherhood of physicians. Physicians are human and fallible. He too had lost patients and blamed himself. In fact, upon further reflection, I realize that psychiatrists are at the epicenter of risk. They see patients who are depressed and suicidal. Psychiatrists always take the risk that a patient will kill himself or herself. And some will, no matter how skilled the practitioner is.

Kill as Few Patients as Possible, a book written by an internist in Los Angeles, helps me cope with failures. The author, Oscar London, says that when (not if) a doctor makes a mistake that causes a patient harm or even death: the doctor should sit down at a desk, take out a Valium pill from the drawer, and call a lawyer. The very sensible matter-of-fact approach somehow comforts me. He also describes how “Dr. Death” sits quietly in the corner of each exam room, making notes on each patient, and adding a patient’s name to his List each time a doctor fails to order the appropriate test or defers on an X-ray.

For me, if I sense Dr. Death in the room, eager to claim a patient, I reach out for a higher power: I send them to see a specialist or to the ER.

Patients should never underestimate the self-flagellation of the physician. It is always in the background: “God-willing, do not let me lose this patient.” The heavy responsibility to mediate with Dr. Death is the hardest part of doctoring.

Addendum: I wrote this before COVID-19 shut down the country. I have not taken care of patients during the COVID-19 pandemic. I can only imagine how stressful it must be. Dr. Death has claimed so many people in the past 18 months, which must take an enormous toll on the mental health of providers.

Janet Tamaren is a family physician and author of Yankee Doctor in the Bible Belt: A Memoir. She can be reached at her self-titled site, Dr. Janet Tamaren, and on Twitter @jtamaren.

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