Medical residents – the young MDs in the years-long, boots-on-the-ground phase of their medical training – do amazing things in academic medical centers like University of Colorado Hospital. Under the supervision of faculty attending physicians, they patch up the injured and help get them back on their feet. They help nurture the sick back to health. They bring babies into the world.
Hospitals like UCH abound with stories of birth, rebirth and rejuvenation. But there’s another reality to hospitals, one that get less attention. Some of the sick and injured – including the babies – don’t make it. Or despite the best efforts of providers and first-class medical care, their wounds, illnesses and disorders render them shadows of their former selves.
Their stories can be heartbreaking. Families of patients can lack coping skills, leading to despondence, even aggression. Medical residents working 80-hour weeks quite commonly find themselves thrust directly into scenes of life-threatening emergency, extreme emotion, and profound sadness. They then exit the room and, for reasons ranging from medical-business mores to the practical realities of busy units, walk into that of another patient, maintaining the physician’s stoic façade, making every attempt to put the unforgettable out of their minds.
A few members of University of Colorado Hospital’s volunteer Good Grief Rounds team. Left to right, former CU Palliative Care fellow and Veterans Administration physician Morgan Elmore; Palliative Care physician Katie Morrison; Palliative Care chaplain Rev. William Jensen; social worker Erin Rosenberg; and nurse practitioner Nicole Rondinelli.
So it should come as no surprise that residents and physicians can bear heavy emotional burdens, or that they burn out, or that they commit suicide at higher-than-average rates. Katherine Morrison, MD, is doing something about it.
Morrison is a palliative care specialist and assistant professor of Internal Medicine at the University of Colorado School of Medicine. For three years she volunteered her time to help residents help each other through the emotional trials of their chosen careers. These “Good Grief Rounds” have earned positive feedback from residents and others who have participated, and Morrison is hoping to develop a formal, half-day training program to spread the approach through UCH and beyond.
Dealing with grief is the focus. Physicians and other health care providers are people, and they’re fundamentally empathetic, too – if you’re not interested in the well-being of others, you don’t go into medicine. Morrison, who was a primary care doctor for 13 years before focusing on palliative care six years ago, recognized that she and her Internal Medicine colleagues had had few avenues to deal with grief (in palliative care, in contrast, she and other physicians debrief routinely with a chaplain or licensed clinical social worker). Physicians in primary care didn’t tend to discuss the emotional aspects of cases with each other or with others in their lives.
“You get to a point where you can’t really bring this stuff home,” Morrison said. “For one, it’s confidential, and two, it would just depress the heck out of your partner.”
Morgan Elmore, DO, MA, who completed her palliative care fellowship at CU in June 2015 and is now a palliative care physician at Veterans Affairs Medical Center in Denver, added that despite working in team environments, health care providers who go through emotional experiences are often isolated.
“That’s how we’re trained,” she said. “You see terrible stuff, internalize it, gut it out, and move onto the next person.”
Good Grief Rounds happen once a quarter over lunch during weekday noon conferences usually set aside for medical education. Internal Medicine residents are encouraged to attend, said third-year resident Tyson Oberdorfer, MD.
“I find them incredibly useful,” he said.
The Good Grief Rounds have themes. In April, it was anger – anger directed at doctors; doctors’ anger at patients, families and other providers.
“I had a lot of anger that came from these difficult patients in critical-care settings,” Oberdorfer said. “Talking through that in the small-group setting, I actually felt a lot lighter afterwards. Just getting it off my chest. Just having a few colleagues hearing me and validating what I was saying – it was therapeutic.”
Being in an elective month in which he wasn’t on the floors also helped him gain perspective, he said. He’s headed to Harvard for a geriatrics fellowship next year and is reenergized and looking forward to it. “But there’s such a need for structured support for residents going through these rotations, and also nurses who spend their entire careers in ICUs.”
Making the rounds
Morrison designed the Good Grief Rounds to include four components. There’s the setting of ground rules and about a minute of mindfulness breathing exercise “to help switch gears from being on the floors to talking about this,” she said. Then there’s a “humanities” portion. For the anger session, they read the lyrics of Peter, Paul and Mary’s “There’s Anger in the Land.” A previous session featured the poem “Airlift,” by Scott Wilson, MDiv, a chaplain at Benton Hospice Services in Corvallis, Ore.
A “storyteller” then shares an experience – what happened, how it affected him or her, and what they learned from it. Residents, faculty, and advanced practice nursing students have done this.
“We’ve had people share some profound stories, people reading their story and crying throughout the whole thing,” Morrison said.
They then break up into small groups of two to four people, where they share their own stories. Morrison and four medical colleagues – a rotating group, she says, depending on who’s available – facilitate.
“It’s experiential. You learn to tell your stories. You learn to debrief,” Morrison said.
A wider net
While there’s little published research about provider grief, Morrison and Elmore say, there is some good science around post-traumatic stress disorder and depression. Debriefing on tough experiences changes how our brains encode and process them. How we encode and process them, in turn, affects how they ultimately affect us, as books like “Buddha’s Brain” describe.
“Very rarely do people take the time to debrief about the bad stuff they see,” said Kinnear Theobald, MD, a fourth-year and chief resident in Internal Medicine. She’s attended several Good Grief Rounds and encourages colleagues to do the same. “As physicians, you have the emotional response that everybody else in that position would have. So this is a time when you can open up.”
Interest in the rounds has extended beyond Internal Medicine, Theobald says. Residents in Emergency Medicine, Maternal Fetal Medicine and other specialties who rotate into Internal Medicine and participate in the Good Grief Rounds have asked her, “Why don’t we do this?” she said.
The hospital’s Occupational Therapy team is doing it, says Erin Erickson, OTD. With Morrison’s help, they launched their own version of Good Grief Rounds in December. Erickson now presides.
Erickson herself was the storyteller in the first session. There had been a patient with whom she had had much in common. Since sharing at the rounds, she said, she’s finally able to talk about her without crying.
“It’s really opened up an avenue for people to discuss difficult cases,” Erickson said. “It should be expanded throughout the whole hospital. I think it’s critical for the work we do and the patients we see.”