S6E7: Grieving Through Medicine

Mariam: Da da da da. Trying to think of a cold open. That's good.

Lina: Wait, did we start?

Mariam: Yeah, we started. You guys.

Lina: I don't see the little lines that show us that we're recording.

Harjit: On the bottom.

Mariam: I think we are. Yeah, they're there.

Lina: Okay. Whatever.

Mariam: Hello, everybody. Welcome back to "Bundle of Hers." This is Mariam, finally back in the virtual studio. I think this is my first episode this season, and so I'm super, super excited to be here with Harjit and Lina. Say hi, guys.

Lina: Hello.

Mariam: I didn't hear Harjit. Did Harjit say . . .

Harjit: Oh, me and Lina said it at the exact same time. So we kind of merged our voices.

Mariam: Wow, you guys harmonized so beautifully. So I wanted to just introduce the topic for today, which is grieving through medicine. Kind of an intense topic to jump into, but we're going to do it.

And the reason I wanted to do this episode is because recently, my last week of internal medicine, I was rotating on the oncology service. That was an incredibly impactful week for me, probably one of the most impactful weeks that I have had thus far in medical school.

I began to think a lot about how medicine shifts when you plan for end-of-life care. And something that I thought a lot about during that week was how we, as practitioners or as future providers, hold space for grief in medicine, not just as providers but also as humans taking care of other humans.

As future doctors and even just at the level of being a medical student, we see a lot of dying, we see a lot of illness, we see a lot of people who are at the end of their life. And one thing that was really valuable from that week was being able to provide that end-of-life care and be a part of a team that had conversations about the end-of-life care.

And then that week also had me reflecting about how important it is as a future doctor, but also again as a human going through this process, to hold space for myself to allow myself to grieve.

I wanted to really make sure we did an episode on this topic because it's something that I feel like doesn't get talked about enough, but it's such a common experience for everybody.

Harjit: Yeah. Mariam, I'm really excited that we're doing this topic, grieving through medicine. I think it closely ties to our larger theme of identity as well because a lot of the ways we shape our views of ourselves are in connection with others, and them being there or not being there is pretty significant and really helps us find who we are as people.

There have been a lot of personal conversations about grieves in our own lives, so I think it's a really important topic to understand the interplays of being in a field where grieving is a fact, death is a fact, and then also knowing ourselves and how we respond to death and kind of merging those together.

We're not given that space. We're not given the tools. We're not allowed that aspect of wellness. I'm saying that with a laugh because you know how wellness is promoted everywhere. But what I'm saying is I think it's so imperative that we have this conversation, and I think I've learned a lot of lessons about myself. So I'm excited to share them.

Mariam: Just kind of bouncing off of that, something again that I noticed . . . This is my third year, so I'm on my clinical rotations, and so much of this process teaches us to deliver care in a very systematic and almost algorithmic type of way.

For example, we are taught to care for patients and to look at their labs, to look at their vitals, to kind of come up with a plan. Sometimes I feel like the way that we approach medicine in that kind of more systematic way and taking care of our patients almost kind of translates into our personal lives and how we also kind of approach our own wellness, interestingly enough. At least that's been my experience.

Harjit: I completely agree with that. I think that's such an interesting observation that I actually didn't think about until we just had this conversation. When you say the word algorithmic, it's not abstract. It's like we have to force ourselves to take those steps and the steps and the steps, and I wonder how it would feel to have a grieving process that was more abstract.

I mean, psychologically, there are certain stages you go through, right? And I'm saying this from a psychiatric perspective.

Mariam: See, algorithmic.

Harjit: Yeah. But I do wonder what the exploration of the abstract would be. Why can't we be that way? It just reminds me of all the ways that we are siloed into being certain ways because of what's learned from us and what we've been taught.

Lina: I think just kind of going from preclinical years and then clinical years, I mean, there's kind of this very . . . a dichotomy way of learning where they're like, "Oh, yes, you're supposed to feel the feelings and the emotions you have with your patients, but also don't feel the feelings you have and the emotions you have with your patients because then you won't be practicing good medicine. But you also still need to feel to practice good medicine." And it kind of puts you in this like, "Well, what do I do? What do I feel?"

And I feel like for a lot of times when I approached third-year and when I did kind of interact with patients that were at the end of life or even just families who did just lose a loved one, a lot of it for me was, "What do I do? What do I feel? I honestly don't know at this point."

And to follow up on your point, Mariam, it did kind of . . . at least a lot of my personal grief that I hadn't at the time really processed came up a lot when patients around me had to deal with grief or their families had to deal with grief.

I know that I lost both my grandparents in my medical school, one in my first year of medical school and one in my third year of medical school. And I feel that whenever I encountered that with my patients, everything that I had not processed with grief itself did come up.

And suddenly, it was just a lot of mixed feelings altogether. It was more of like, "Am I supposed to be feeling this way? Why is this coming up? What am I supposed to feel?" There isn't really much direction other than that kind of yes or no situation. And at least to my observation, people tended to be on one extreme or the other of it.

Harjit: Thank you for sharing that, Lina. I remember when both of those events happened, and they were both personal, but then you also had to move on with your professional life. People that are so close to you, when you see those same kinds of patients or something that triggers or reminds you of that, every time those wounds are opened again.

Also, when do you process death when you're in medicine? We don't have time or space to do that. And not only are you trying to process your own death, but then in the future or even now, you'll see deaths of your patients that you are taking care of, right? I think about that a lot.

Mariam, when you brought up this conversation about grieving in medicine, I thought about how I deal with grief on a personal level. There's something funny that someone once told me, which was my sister. My grandma passed away. My grandpa passed away. I've had people in my life pass away and I'm very unreactive.

In my Sikh belief, people will come into this world and they'll leave this world. So that's how I thought I was coping, that people come, people go. Death is a natural part of the process of life, so why should I feel sad? They had a full life here. They were here in the ways that they could be and now they're merged with God. That's my belief system, right?

So I had a very ambivalent, I would say . . . I have a very ambivalent nature. Sorry, I can't say the word. This happens to me a lot. I have a very ambivalent nature towards death. A part of me wonders where that comes from. One is a culture within my community being Punjabi and Sikh. And so it's just a part of life.

Second is it's also not talked about a lot. I remember in the '80s when that whole Sikh genocide happened in India. My parents didn't tell me about that. I didn't know about that until I was in my 20s. I had to learn about that myself. So it was not talked about.

And then third, I think I go back into my personality of being, "I need to take care of other people. People don't need to take care of me." So that's another reason why I'm ambivalent.

The reason why I bring this up . . . I'm a doctor now, right? In my first year as an intern, I had two deaths of patients I took care of. That was really difficult for me because I was their provider. I was the first person that saw them and I felt responsible. They were my patients and it was my patient that died, and I didn't know how that was going to hit me.

And because of the ambivalence, I was fine the first two or three weeks. But by the end of the year, I think it really, really impacted me. It felt harder than I would even say a personal death feels, which might sound freaking crazy, but I think it was the responsibility aspect, right? This person is here to seek care so they don't die, and they died as a result of my care, right? That's what I thought.

But I want to correct that. It wasn't they died because of a result of my care. That's what was going to happen. I just happened to be there at that time. I did everything I could appropriately and I did have support.

Mariam: Yeah. I mean, frankly, especially as an intern, the way that your hours are, the intensity of the work that you're doing, with what time and what energy, sometimes it takes a while to process.

I mean, in general, I think it takes a long time to process losing a loved one or losing somebody that you took care of. When you're going through this really, really intense training process, again, nobody gives you the time or the space, right? You have to figure out ways to make that for yourself in medicine.

Just now into my clinical years, I haven't had personally experienced a patient death where I was directly responsible, but I have experienced a couple of patient deaths where I was part of the team that was following the patient.

I remember one day during rounds we were rounding on one particular patient. We were essentially delivering bad news. It was essentially delivering a timeline of, "This is how long you have."

And the person that was in charge of doing that was one of the senior residents. She kept it very stoic. She was very much like, "This is what's going on." She was clear in how she was speaking. She was very transparent. She answered all the patient's questions. She answered all the questions of the patient's spouse who was in the room.

And then she walked out and I remember she just started bawling and then she immediately was like, "I'm so sorry. I'm so sorry. I don't know what got ahold of me. This is so unprofessional." She just started freaking out. And I was like, "That is not unprofessional." That shouldn't be where our mind jumps to, right?

But the whole point of this story is that through this training process, we're taught that we have to bounce back really fast. She was expected to work for an additional 10 hours that day, a full 12-hour day or whatever, and then go home, process it on her own time.

Thankfully, we had a really kind attending who was like, "Go grab a coffee on me." He at least allowed for her to have that space. But it was so interesting, she came up to me later and was like, "I apologize for doing that." And I was like, "You should never apologize for having that space. I will cry with you." We should be allowed to have that space. It should be a normal part of medicine.

And I think that I have had really good experiences with attendings, with residents who encourage me to lean into that side of being emotional and connecting with my patients and allowing myself space to take care of myself.

But the difficult thing is when you're in it, there's so much that you're responsible for. There's only so much that you can take as a human being in that space. We automatically start to numb ourselves, and that's just part of coping, right?

Again, this is all kind of more just me reflecting. I'm not saying that it's good or bad the way that we individually cope. Harjit, you mentioned that you lean more towards ambivalent. I'm not saying grieving should look a certain type of way, but I just think it's important to have an honest reflection on how it looks different for everybody, but how this system also is, I think, just avoiding it as much as possible because it doesn't give us the space to do it.

Lina: I agree with you, Mariam, in the sense that in the beginning of my third year and my rotations I did experience seeing losing patients and me being part of the team. I think a big thing that I noticed was like, "Oh, you're just kind of at the beginning of the year. It's fine." In a sense, moving on or, like you said, avoiding what was happening. "It's not our patient. We're just students. We have a huge list of patients. They're all kind of affected in a way or another. Let's just move on, in a sense."

For me, a lot of the pain came from, "Is no one going to acknowledge this? Is no one going to have any type of reaction? Wait, should I not have feelings because, yeah, they're right, this isn't my patient? I didn't even know this patient. I just heard them being presented or being talked about."

And so I think that back and forth of, for the most part, not acknowledging it really did hurt in a way. And that's kind of what brought up a lot of my grief as well, because it turned into something more personal for me.

One, I felt guilty for having those emotions because no one else on my team had those emotions. I'm sure they did, but I didn't see that at the time because I wasn't really part of the team.

And then two, I never even processed my own grief. So now it feels even more guilt.

I think towards the second part of my third year, there was a particular patient that did experience a loss and I remember that day, I had only just met the patient that morning, but I remember going into the on-call room after the loss happened and just crying so hard.

My attending came in and she was like, "It's okay to feel what you're feeling." She's like, "This has happened many times, but you know what? I still react the same way that you are reacting, and it's okay." And I think having that validation for me made me just remember that, "No, I can feel this. I can process it in a way. I can be as sad as I want to. I can ugly cry about this, and it's okay."

And then they gave me the day after off and gave me my time to really process this loss and really feel for that loss. I think having that validation and having that experience truly gave me a way that, "You know what? We can be better about grief."

It is better to be in that way that we feel and we have the emotions and that we process it as we go instead of avoiding it, because avoiding it is what hurt me in the first place.

Mariam: What I think is really an interesting reflection is how medicine has its own way too of when we're taking care of really sick patients and we experience these losses, they inevitably are going to remind us of the people that we've lost or the really sick people in our own personal lives that we love.

Lina, what you experienced, especially when you started medical school with your personal losses in your family, I remember us talking a lot about, "This person just reminded me of my grandmother."

It's interesting because we separate our personal lives from who we are professionally, but there's really no way to do that, especially when it comes to this conversation about grief and about losing loved ones, because it does impact you. It finds a way to always come back. It always gets to you.

Harjit, you made this point of sometimes the people that you lose on the wards, it impacts you even more. I think you said something like that.

Harjit: Yeah. I think the point that I was trying to make and something that Lina also mentioned is it doesn't matter how deep you are in their care, anyone can get impacted. It doesn't matter how you react. You can't quantify grief because it's almost an unquantifiable thing.

And I think that's what the important point is, that to make ourselves feel better as an institution or as a system, we want to box things, right? Like, "Oh we'll give you tomorrow off." But I processed it five months later. We can't put grief in a box. That's what I was trying to say.

Lina: I think it's the limitations that we put to grief and the timelines that we put to grief that we need to kind of step away from. And I think I've learned that from you especially, Mariam. I shouldn't expect grief to finish at one point or to be okay at one point. I need to accept it as it comes, and I need to feel what I feel as it comes.

Mariam: For sure. I remember when I was in undergrad, I had recently lost my father. I lost my father actually my senior year of high school. But in undergrad, I feel like I was essentially grieving his loss because I didn't have a lot of time to do that as a senior in high school going through all these transitions.

And I remember having these moments where I would be walking back to the dorms from class and then I would feel the tears come on. I'm a crier. That's how I cope. That's how I grieve. I cry at least once a week. And I remember just getting really annoyed at myself because I was like, "I can't just keep crying and losing it because I won't have time to study and I won't have time to be a functional human being."

And so I remember I used to do this thing where I would go into my dorm room, and this is going to sound nuts, but I would set like a 20-minute timer and I would just let myself cry for 20 minutes. And then after the 20 minutes was up, I was like, "Okay, you're going to go splash some water on your face, and then you're going to go get it together and study."

Honestly, it kind of worked for me because it allowed me to get my emotions out and it allowed me to have that time and space. But it's really funny how systematic I was even back then about how I wanted to process. Instead of giving myself the rest of the night off, I would be like, "No, you're going to go study." And I guess maybe that's . . .

Harjit: How does this not surprise me about you?

Mariam: I know. Well, I guess that's what I needed at the time. Again, I don't think it was necessarily the wrong thing to do. I was a teenager at that time, right? Like late teenager. I was much younger.

I think I thought I needed to get through it and if I allowed myself these little bursts of crying for a couple of years, I would get it all out of my system, and then I would be a new woman. I wouldn't have this burden of sadness and loss carrying over to me.

Spoiler alert, surprise, surprise, it still is with me to this day. And I've come to realize me experiencing loss, particularly through my father in this example, that's something I'm going to carry with me until I pass away. That's something I will never forget. I will never stop feeling.

We always think that we just need to cry it out and we're going to be fine, and we've processed it, and it's done. Sometimes that's what we need, and sometimes it does work, but I also think a lot of us don't realize how grief is just a lifelong process. It's something that never goes away.

Lina: One hundred percent.

Harjit: And I also want to say, Mariam, that one thing we didn't mention is that grief is also not only a physical death of somebody, but there are a lot of things that cause grief. I mean, people have had breakups before. I've heard those feel like grief. It's an example.

What I'm saying is there are a lot of things that can cause the grief, but the one that's kind of in our face I think in medicine is death because it's such a big concept. We're trying to help people stay alive, or if they do die, help them die in dignity, right?

Mariam: Yeah. I love that. All of this kind of reminds me of a quote by Elisabeth Kubler-Ross. Some of you have probably heard of her because she . . . Harjit, you should have heard of her. She does psych stuff, I think.

Harjit: I mean, I remember concepts, but then I forget who said them, but that's why we have Google.

Mariam: You'll know the concepts. She's the one who kind of talks about the five stages of grief.

Harjit: Yes. Okay. I know her.

Mariam: So she goes into . . . I'm trying to remember all the five stages of grief. You have denial, you have bargaining, depression, anger, and acceptance. That might not be the right order. But essentially, she was the one who kind of highlighted that.

I was reading into her work a little bit because she does a lot of work on end-of-life stuff and the process of grieving, and she kind of deals with the more psychological side of it. And there was this really beautiful quote that I think kind of summarizes a lot of what we're alluding to in this episode.

It starts with, "That's what grief has taught me, that I can survive. I used to be afraid that if I experience grief, it would overcome me, and I wouldn't be able to survive the flood of it. That if I actually felt it, I wouldn't be able to get back up. It's taught me that I can feel it, and it won't swallow me whole. But we come from a culture where we think people have to be strong. I'm a big believer in being vulnerable, open to grief. That's strength. You can't know joy unless you know profound sadness. They don't exist without each other."

I think that that's a really beautiful way to kind of summarize everything that we have talked about today.

Harjit: Yeah. That's such a beautiful quote. Really do understand and feel emotions, and to feel the opposites of emotions, you have to feel all of these things. And I really appreciated that.

I think our conversation about grief in general, in medicine particularly, is one that also requires some activism on our part in the sense that we should be fighting for spaces and places for us to have these processes. You already talked about the stages, but some of them come before, some come after, and then sometimes you're looping in them all the time.

And I also wanted to thank you for sharing your story about your father passing, Mariam. I think as I've gotten to know you more, I do know how he shapes your life, both when he was alive and now that he's not here anymore. I get to see that through you and the way you talk about things and how that impacts you in medicine to have someone in your immediate family that is not with you.

Mariam: My dad passed away when I was 17. He had a form of cancer that was very late stage when it was caught and passed away within a year. So it was a very unexpected thing that me and my family went through.

And it was also at a really interesting time because, like I kind of mentioned before, it was my senior year of high school. I was getting ready for college. A seemingly very normal life before and then everything just kind of changed.

I mentioned that throughout undergrad, I was finding ways to process that grief because I didn't know how to. I was 17. I didn't have very good skills, to be honest with you, because what 17-year old really does?

But it's been actually about 10 years. I was reflecting earlier this week. It was the 10-year anniversary of his death. And it seems crazy to me that it's already been 10 years. But while I was kind of thinking about this episode, I remembered that I wrote a poem about him. I think it was about a year ago or something like that. I had a really hard day at school. I don't remember what it was, and I just was feeling really low.

I have this picture of my dad right next to my desk. I just happened to be sitting at my desk, and I looked over at it, and I think that's kind of what had me start crying. And all of a sudden, I was like, "I miss him so much."

I think, again, going into this concept of grief, a lot of grieving is recognizing the sadness that we feel and the hardship and the uncomfortable moments that we remember with our loved ones who've passed, but also the beautiful joyous things that we miss and almost the little things that we miss with our loved ones passing. And that's really what this poem is kind of about.

So I will start to read it.

"Sometimes I see myself through your eyes. I'm pouring coffee and rushing to my room to review my notes for class. I feel pride in your pride. I see the hardworking daughter you wanted and the happy daughter you realized you needed.

"Sometimes I see myself through your eyes. When we used to drive together to see the autumn leaves, and you look over at me, and you feel a calm peace around you, you feel like you did all the things in life right to get to this moment.

"Sometimes I see myself through your eyes. When you were gasping for air, a side effect of your cancer treatment, and you notice I can't look you in the eye. I rush to say goodnight. I give you a kiss on your cheek, and you feel ashamed of me but not as ashamed as I feel of myself.

"Sometimes I see myself through your eyes. When I'm getting ready in the morning as I glide the black eyeliner onto my eyes that are shaped just like yours, when I smile with the same smile that welcomed me into this world. And when the smile quickly fades, when one thought rushes to another, the same look of worry that you see in yourself. I run before I'm late to class.

"Sometimes I see myself through your eyes. A scared little girl, I start to feel deep shame for crying. You seem disappointed in me, even say my name sternly, impatiently. I want to crawl in a hole and only ever show you the brave side.

"Sometimes I see myself through your eyes. I'm running through pathways in school, seeing patients, trying to figure out complex diagnoses, speaking up and taking space. You're emboldened by the woman that you've raised. You didn't realize that she was what success could look like.

"Sometimes I see myself through your eyes, and sometimes there's nothing in the world I want more than to see what you actually see."

Harjit: That's beautiful.

Mariam: Thank you. Okay. I'm emotional.

Harjit: I want to thank you for sharing that with us. I always wonder what Baba Assadian would be like too when you talk about him, and it's beautiful that you were able to express that.

Mariam: Well, thank you for allowing me to have that space. I love you guys. So with that, we're going to go ahead and conclude the episode. Thank you all for listening.

Please follow us on Instagram @bundleofhers. And if you guys have a personal story of grief, we would love for you guys to share. For those of you that share, we have these lovely pins that say "Power Through Identity" that we would love to give out.

Harjit: So happy everyone could listen to us.

Mariam: Yes. Bye. We love you. Bye.

Harjit: Bye.