At the beginning of a career – sometimes when viewed through rose-colored glasses not yet spoiled by reality – you hope to be able to lose loss to stay away. Somehow you feel like if you just try hard enough – practice psychiatry in the best way possible you can somehow prevent death by suicide. This is obviously magical thinking, and you begin to realize that there will be a loss. You will scour your practices and your documentation to ascertain if you could have done something differently that perhaps the outcome would have been different. We are not able to prevent what we cannot predict; we cannot change outcomes that were not ours to change. These lessons come for some of us quickly, and others are granted more time in our careers before we experience the first loss – even more painful than the ones we blame ourselves for. I suppose part of us knows that these losses will come. What I wasn’t prepared for were the losses incurred over a career that were not the result of illnesses that I have been charged to treat. The deaths that are caused by age or any myriad of other medical illnesses- the outcome of lives lived is the inevitable end that comes to all of us.

Now nearly 20 years into a practice in which I have had the ability to see individuals weekly or monthly over nearly two decades – I am now more frequently dealing with loss. I have always used compartmentalization to cope with and make sense of these losses. It is increasingly becoming more difficult to proceed in this manner. Though sometimes there are those instances when a brief encounter translates into a profound feeling of loss or connection – more often it is the frequent contact over months and years that tends to etch a person into memory. I have sat with individuals thorough many of life’s sorrows but also the successes – the holidays and years tend to tick by really without much notice. I am privy to some of their inner thoughts and fears – I have gotten to know their families, some in person and some simply in my own mental imagining from all the pieces they have provided me – sculpting a picture of what life looks like outside in the world. They often become in tune with changes in me – offering their opinions on a new hairstyle or asking me if I am feeling ok on a day I may seem less cheerful. I was never able to put on the face of the stoic therapist that I had aspired to early in my career- and settled for a more vulnerable one whether I intended this or not. I have grown to understand that most patients do not expect you to have all the answers but rather want to know that you will listen and that you care.

The stark realization that the appointment last week or last month was the last time you will see that patient hits hard – really, hard. I don’t know if they would have ever repaired that relationship with their son or if they would ever be able to take that trip, they have been imagining. Loose ends – keep adding up – there will not be any more standing appointments on the second Tuesday of the month where I may find out those answers. I have made it a practice to tell my patients regularly how proud I am of them, but I will be left to wonder if they really knew – if they really understood that our time together affected me, too. Sitting at my desk wiping away tears, I ponder all these things as I prepare to end another day. As I turn out the light and close the door – I hope tomorrow will be a day that I share a success in one of the sessions.

Courtney Markham-Abedi is a psychiatrist.