EP 2: Grief and Grieving in Medicine

Episode Description:
Exploration of the importance of addressing both personal and professional grief as a form of self-care for healthcare workers.

[00:00:00]Dr. JB: Welcome back to another episode of Hope 4 Med. I am Dr. JB, your host. And today we have a very special guest. His name is Dr. Anthony Galanos. He is a palliative medicine specialist in North Carolina. Dr. Galanos, please tell us a little bit about yourself and your background and how you got to where you are today.

[00:01:03] Dr. Galanos: Owe it all to my mother and father. My dad had this incredible work ethic that all three of his sons inherited, seven days a week and holidays. My mother was a short Greek woman, never went to high school, constantly worried about others, very pleasant. One of those people that was not outspoken, never drew attention to herself. And when patients asked me where I got my bedside manner, it’s clearly Inez Galanos.

[00:01:41] My official title is clinical director, Duke palliative care, not chief, not director, clinical director. I happen to be, and I’m grateful to be a full professor with tenure.  And I’ve been at Duke. This is year 32. So I’ve been at Duke 30 plus and, was a geriatrician before starting the palliative care program in 1998. And it has grown and we have palliative care teams at Duke University Hospital, the VA across the street, Duke Regional Hospital here in Durham and Duke Raleigh, which is in Raleigh.  I don’t want to represent Duke, though I just want to represent Tony Galanos.

[00:02:40]Dr. JB: Dr. Galanos, you were one of the first physicians I spoke with regarding the idea of Hope4Med and you did not show any hesitancy at all in terms of supporting this mission. Why was that?

[00:02:54]Dr. Galanos:  I think your idea of focusing on the mental health and welfare of doctors and other providers, is genius. I spoke to first year class of PA students at Rosalind Franklin University in Waukegan, Illinois, just above Chicago. And the two topics were not sexy, aging and end of life. And then the second hour was Grief 101 and they really liked the first lecture, but they were off the charts interested in the second lecture Grief 101, which is a mostly about personal grief, but also some about professional grief.

[00:03:50] And obviously for somebody who has been in the trenches as long as I have, the two exacerbate, one exacerbates the other and vice versa. You cannot live long and not start to think about people you loved and lost when you see somebody in your clinical practice that reminds you of them. And I certainly have had that experience too.

[00:04:18] I think the psychiatrist pathologized it and call it transference, but I call it just living and having loved family members and seeing people in the hospital or your practice that resembled them. I think it’s pretty natural to think about them in that moment. Don’t you?

[00:04:40]Dr. JB:  Yeah, I agree wholeheartedly.

[00:04:42] Dr. Galanos: Yeah. It’s curious to me. And again, this is one reason I’m so grateful for your ideas. It’s curious to me that if we know that everyone’s gonna to die, why don’t we talk about that there’s going to be a bunch of people who grieve right after and are gonna to grieve a lot longer than right after, but depending on the relationship, for weeks, months, to years. And there’s a lot of, not a bunch of literature, but there’s enough literature out there that talks about the different kinds of grief vis-a-vis the different kinds of relationships and, I, for one , admire the psychiatry discipline for talking about and categorizing grief. But I think we still don’t know enough about normal grief or at least we don’t talk about it.

[00:05:47] And it’s just not on the tip of people’s tongues. In fact, it seemed to have been swept to the back. So  I’m not just interested in this topic because of COVID though for goodness sakes , if you have no interest, think about that. And I’ve been very impressed that every time I’ve given the Grief 101 talk to either learners or attendings, the response has been very good and people wanna talk about it. And sometimes I even get them to talk about their own stories, but for the most part, the learners do that instinctively. There was a young woman yesterday on the Zoom who started talking about the death of her mother. You would never hear an attending do that, but you will hear attendings say  my work is hard and  I have to set boundaries or I cope this way, or I cope that way.

[00:06:49] And more work I think could be done, but I’m proud to attack the problem in my local shop because I think it’s a, it’s an untapped need.

[00:07:03] Dr. JB: I agree with you. I think it’s so important. I think too often we forget about our own humanity and the way that experiences with our patients, as well as our personal life, affects us in our day to day.

[00:07:21]And we have this baggage, for lack of a better term, that really contributes to the way that we see things and the way we react to certain situations. Yeah , and it’s important to just be aware and cognizant about that. And it’s not something that should be swept underneath the carpet, right?

[00:07:43] Because what happens when you keep sweeping things underneath the carpet, that dust that you just, oh I’m just, I don’t want to find a , a dust pan, so I’m just going to sweep it under here. You keep doing that and you keep doing that. It, it transitions from just a few dust particles into this mountain.

[00:08:01] This volcano really, that’s just waiting to  erupt and then it’s going to erupt when you least expect it , and it’s just like small things that will just trigger it. And you’re like, where’d that come from? And then you realize that there’s so much underneath the surface that you just haven’t been dealing with or coping with or processing. And so this is a very, very important topic.

[00:08:25] Dr. Galanos: Yeah, I am impressed with what I’ve read, but what I have yet to see and would be very interested to learn if it’s already been done, but I’ve not seen the topic of cumulative grief talked about in the literature. By that, I mean, someone like you, who is a veteran of the emergency department, somebody like me, who’s been doing geriatrics and palliative care for 30 years. I saw a lot of, that’s a lot of deaths. That’s a lot of sadness.  There’ve been a lot of younger people under our wings who look to us for how to manage it. And I specifically have been looking for the topic of quote, “cumulative grief.” I haven’t found it though, I’m not the most facile with a computer, so maybe my younger colleagues can find it.

[00:09:26] There’s stuff on professional grief. There’s literature on particularly on the ICUs and families that experience a loved one dying in the ICU. And there’s a lot of literature for our nursing colleagues, about the stress of working in an ICU. But I recently panned the literature and I didn’t see much on the doctor in the ICU and the amount of death and dying there and I’m sure in your role in the ER, you see a lot of critically ill people that you have to ship hastily to the ICU  and you must wonder, so how did that story play out? So I worry for, for both the people who have their face in it and see what happens. And I also worry for those of us who don’t see how the story ends and because I think we want completion.

[00:10:28] I think we want to know that we made a difference and maybe that we even just didn’t make a difference, but actually provided some comfort or some education or something that would mitigate the bad outcome that’s about to happen. And so that’s, that’s where my thinking has been, of late. And while I care very much about families and the public, I’m starting to worry about our own union, particularly docs because I think the attendings are the ones who are left out. When we think of great educational interventions or mental health interventions, it’s always about the students and the interns and the residents appropriately so, but I’m not so sure that those who’ve had a lot of cumulative experience are doing it right just because they’re older.

[00:11:27] Dr. JB: I agree with you. I think that part of the reasoning behind me creating this business that focuses on health care workers’ mental wellness is there’s no uniformed outlet really.  You know, it’s kind of, we’re all left to deal on it, on our own.  And as an emergency room physician we, say we have a critically ill patient that presents and yeah, we try our best to get a sense of what’s going on and get them to where they can get the appropriate care as soon as possible. But sometimes the progression is too quick and we’re not successful in getting them out and I find those patients for me honestly, are the most difficult, and I do have to take a pause. Like for instance, I remember a patient who came in and as soon as I saw the EKG, I knew this patient was having an MI, right?

[00:12:37] Activated cath lab, everything, like it was fast, within five minutes. Young patient, but the patient, decompensated in the emergency department, before we were able to get him out of the emergency department. So he came in, walking, talking, he’s like, oh I just feel a little discomfort in my chest, like we had a full conversation and before my very eyes, he decompensated and I wasn’t able to get him back.

[00:13:11] And so you leave that situation and you ask yourself, what could I have done differently? You know? And it stayed, it stayed with me for days.

[00:13:24] Dr. Galanos: Yeah. I think the woulda, coulda, shoulda game is a tough one for docs. On the one hand we want to learn from whatever we’ve encountered. I’m not going to say learn from our mistakes, I’m going to say learn from the clinical experience and to do that, we have to rewind the tape and see was there any opportunity to do things differently or better, but for the most part, if you can’t compartmentalize the woulda, coulda, shoulda, it’s going to torture you and hurt you for the next time you encounter anything similar.

[00:14:08] There’s a great expression in sports and you know, you trained in North Carolina so you know that sports is the universal language here, so it’s an apropos metaphor, but there’s a great expression that says “don’t let the same play beat you twice.”

[00:14:27] And that’s, or you’ll hear another one, “good cornerbacks on the defensive backfield of a football team have short memories,” meaning they don’t remember the last time somebody ran by them to catch a touchdown pass, cause if they did, they’d be analysis paralysis. Right? And I love the word you just used.

[00:14:51] I don’t know if you meant to, you said, “take a pause.” And the palliative care literature is pretty robust about if something terribly sad happens, the whole team, rather than having a debrief and psychological revelation, just stop for one minute, acknowledge that something sad just happened, take a pause and then move on.

[00:15:21] And I’ve been very proud of the residents in internal medicine here. I’ve said that many times when I do a debrief with them after hard events at work. And this has been something simple and fast and it’s becoming, it’s not there, but it’s becoming part of the culture. And if I’m hearing you correctly, that’s why you’re starting this program, this business that our culture does not acknowledge sadness, but we, in fact it, it reinforces you for just to keep moving and not processing what you experienced. So I love it that you said I had to take a pause and it also made it sound like I can absorb a lot of insult, but every now and then there’s something that pushes over the line and I have to take a pause and I hope we in medicine can start to be better to ourselves so that we enjoy our work more and last as long as I have.

[00:16:30] Dr. JB: Exactly.  Yeah, because the thing about it is , we’re not superhuman, right? We’re all human and the analogy that I’ve  been using as of late is  just, just thinking that, yes, we’re all human, we’re all different  there’s only so much weight that a human being can, can hold until their knees start to buckle and that weight is different for every person, but at some point, every person’s knees will buckle.

[00:17:10] And so the goal of having this conversation, the goal of this company, is to serve as a pop-off valve. Right? So that you don’t ever get to that point where your knees buckle, so that you have an outlet that’s safe, that’s welcoming, that’s non-judgemental, so that you have this community. That you realize that you’re not in this alone , that we all are going through similar experiences , and acknowledging the stress and trauma associated with our day-to-day existence and that it’s not only the patients and the patients’ family who’s affected in the moment, but it’s the healthcare workers that are also affected by what that patient and family experiences and goes through. Yeah.

[00:18:09]Dr. Galanos:  A clinical social worker pointed out to me one time , when you fly, which many of us haven’t done a lot since COVID, but when you get on an airplane, it says to put your oxygen mask on first, that’s another great metaphor.

[00:18:29] Take care of yourself first, and then you’ll be able to take care of others.

[00:18:35] Dr. JB: And isn’t that what we tell them? Isn’t that what we tell our patients? Yeah. But it’s, you know, we can, we can share that information with them, but then when it comes to us, following our own advice, it’s challenging for some reason.

[00:18:50] Dr. Galanos: Yeah. Well, eventually when the medical culture takes a look at itself and I think COVID has been good at, at least making the press say “my goodness, look at what this healthcare system is doing and how, stretched and limited.” And you hear provider after provider get on the news and say we, “we can’t do any more than what we’re doing.”

[00:19:20] We have nurses who’ve worked teen days straight without a break and et cetera, we’ve had many providers on the news, tell the public people are dying alone and that is so stressful to watch. So I think there might be an opportunity post- COVID to build on what we’ve started.

[00:19:44] At the same time, and I hope this is not too controversial, this healthcare “hero” label has been offensive to many people who wear the white coat because they know who really does do the heavy lifting in the ER and the ICUs and there are certainly healthcare heroes, but not everybody who has a stethoscope in their pocket.

[00:20:11] And I think that’s actually hurt the mental health of providers who feel the need to do more because they’re not, they’re not doing what some of their colleagues are doing. Have you heard that?

[00:20:28] Dr. JB: I have, I’ve also, I came across an article recently written by a healthcare provider who said that they don’t feel like heroes anymore.

[00:20:39] It’s difficult, on, on a couple of levels.  That title of hero, and one line, I can understand the reasoning behind  why they created it because  while some people could stay at home, right, and shelter in place, our duty as a healthcare worker was to run into that burning house.

[00:21:09] I remember when the pandemic first started and I was speaking with some of my friends and they’re asking me, well, “you’re a mom, you have young kids. Are you going to keep working?” And I said, of course I am. I’m an emergency room physician. I am the, one of the first people that these patients see when they come into the emergency department, it’s my job to be there, to take care of them, to the best of my ability. And yes, I will, will do my due diligence in trying to protect myself but that’s what I signed up for. I came into healthcare, we always say we come to help people, and in this moment, these are people in need.

[00:22:01] So I’m not going to stay home. I’m going to go to work. And I know that it’s dangerous. I know that there’s a lot of unknowns. My day-to-day life in the Emergency department is dangerous. Right? Because we never know what’s going to come through the door, even before COVID you had no idea, right? Oh, that was a biohazard, like, oh, I got exposed to?

[00:22:21] Like, but that’s what that’s part of the day-to-day risk of my existence. So I can understand why people say, “Oh, because you continue to knowingly put yourself at risk, we should title, we should call you a hero.”  But on the other hand it’s, I view it as I’m just one human trying to take care of another human being. And, and I can see how if you are not on the front lines, how it could affect you, because you’re like, oh , people see you, they, oh, you’re a doctor, but  you aren’t a specialty, not in the ED or ICU or whatnot and so you are actually a little, a few steps removed from having to  necessarily come face-to-face  with patients with COVID on a day-to-day basis , how it could affect you mentally.

[00:23:13] I definitely can see that.

[00:23:16] Dr. Galanos: Yeah, well, it’s actually been easy for me, but that’s because I’m older and wiser and I never bought into the “hero” thing, and I always thank my colleagues who are heroes and I just didn’t buy into it. I think when they started doing that, they didn’t have an idea of how long the pandemic was going to last.

[00:23:43] It’s that chronic, unrelenting high demand, low control. And I think that’s the definition of stress. High demand, low control and there’s cumulative grief.

[00:24:01] I think cumulative stress is the one that kicks in the back of the knee and makes the knees buckle. Right?

[00:24:10] Dr. JB: Yeah.

[00:24:11] And then it leads to burnout.

[00:24:14] Dr. Galanos: Yeah. Yeah. And I, I’m grateful to see that burnout entered the literature years ago and there’s a pretty, or there’s a lot of studies about it and scales to develop it and, so that was there before COVID.  I mean, even that, the word burnout begs the question of what kind of culture have we created for providers and can the culture be changed or should we be investing more in building the resilience of providers? And that certainly has become a very important word, resilience, and our psychology colleagues have added to the literature in a very productive way.

[00:25:08]So it’s kind of, but I– I’ve yet to hear, I don’t, I don’t think we’ve made decisions about what’s the best way to go. Maybe it’s a combination of helping providers build resilience and at the same time, helping them express their grief, sadness, stress, burnout, et cetera.

[00:25:34] Dr. JB: I agree with the latter. I think that when, when we focus too much on resilience, the emphasis is on “oh it’s providers, it’s the provider, it’s the provider; if they just were more resilient then things would be better.” And I don’t buy into that, I don’t believe it.  I think there is a role for addressing the individual needs of the providers and there is a role in addressing their stressors and things of that nature.

[00:26:06] But I think that only makes up a very small piece of the pie. If we’re going to put numbers on it we’ll say maybe, maybe 20%, the rest of it is the environment that the provider finds themselves in. I think you’d be hard pressed to find a healthcare worker who has left the profession and when you ask them, why did they leave? They say, “oh, because I didn’t like the patients.” Yeah. They love the patients. That’s what, that’s why we do this work, is to take care of our patients, but it’s the 80% that drives us away. And so in terms of tackling this, this topic of burnout in medicine, I think it behooves us to keep that in the back of our minds, that, it’s going to take at minimum dual approaches, maybe even more. One that focuses on the individual, right, their mental health or needs, and the other one that focuses on the environment.

[00:27:26] Dr. Galanos: Yeah. It’s and/with not either/or, I, I agree. And I think there are a lot of providers who I only know anecdotally, but I’ve heard people say “resilience puts the burden on me, like I haven’t done enough to build resilience.” Whereas there, if something’s sad, it’s just sad and if I see it as that, it doesn’t matter how much resilience training I’ve done.

[00:28:01] In the early days of the pandemic, when people were saying it’s not true, or you can’t make me wear a mask, social psychology would have been so helpful, had they been invited to the table. Social psychologists would have understood why people’s behavior was detrimental to their own health or to the health of people around them. And all the research that’s been done on thinking like a mob and thinking, once, social psychology when I was at Duke a long time ago, as an undergrad, studied things like how many people do you need to have around an emergent situation? Where instead of action, no one does anything cause there’s eight people there instead of just two. And I think that was a long time ago when I was an undergrad. So, but I’m going to guess that once you get past eight people, if I recall my, my lecture correctly, people don’t, don’t act, they don’t call 911.

[00:29:09] So you need someone that’s fewer than six. Someone that tends to the emergency and looks at people and gives them jobs to do. And they act accordingly. So I, I hope as we go forward, whether it’s for resilience training or for professional grief work, that we lean on our colleagues that are outside the box, our box, such as social work and psychology.

[00:29:44] Dr. JB: Yeah. I agree with you. I think that, taking other people’s experience and perspectives into this equation is really needed to really try to find out the best or most effective solution, because currently where we find ourselves is very unsustainable. And the issue is if you take a step back and you look at our country and the world, but we’ll just focus on America for now, you realize that currently we do not have enough healthcare workers to serve our population, as it stands right now. And so we’re opening up more medical schools. We’re opening up more programs for PAs and nurse practitioners and whatnot to really be able to serve the needs of the masses.

[00:30:37] However, while we’re doing this, trying to produce more, if we are not retaining the ones that we currently have, then this is going to be a never-ending battle. There’s natural turnover, right? Because we all retire at some point. So, the ideal setup, right after you’ve jumped through all these hoops of undergraduate training and was able to be accepted into a health professional school, is that once you get there, we retain you. We create the supportive environment that helps you grow and prosper into a healthcare worker and that you stay in your profession until you retire.

[00:31:33] And you will have some of those people, some people may think they have one view of “oh, this is what medicine was about” and didn’t completely really understand, maybe, but I don’t think that’s the majority. I think the majority had a decent understanding, not a complete, but a decent understanding of it going into it. And something happened from the second they started their health professional training to when they started practicing as a licensed professional in whatever field they chose that jaded them, that burned them out, because I argue that burnout starts in your health professionals school, the medical students, the nursing students. And maybe it’s just transient, you sometimes I just feel really burnt out and then somehow they’re able to build themselves up and get through it and they feel good. They, they have highs, they have lows, they have highs, they have lows. But some don’t make it through their health professionals school. Some don’t make it through their postgraduate training. Some never practice even after making it through their post-graduate training. And then others leave at any point throughout their career.

[00:32:48] Dr. Galanos: Yeah. There must be statistics on that but, I don’t know them off the top of my head, but I’ve certainly anecdotally seen people who finish med school, finished residency, and then picked another profession.

[00:33:04] Dr. JB: Yeah. And so I’m like, why? Like what happened? Yeah. So I think these are also  some of the topics that we’ll be delving into and talking with some health professionals who’ve transitioned out, then trying to figure out like what happened , what needs to be addressed in terms of fixing, or at least starting to take the steps towards, towards fixing the problem. But I do, agree with you that cumulative grief and addressing grief is of utmost importance because it is not addressed.

[00:33:42] Dr. Galanos: Yeah. Yeah. I found a nice article last week, I think it’s 2017, that made a direct link between grief and burnout.

[00:33:58] I think there’s- burnout’s so complicated because it could be everything from the electronic medical record to “I really am tired of doing what I’m doing.” So I don’t want to say grief is the number one reason, but I do want to say if we don’t tend to things like grief, they become more powerful and more important in the equation. And it seems to me that people in healthcare of all professions should acknowledge grief, both in our patients, families, and then our friends and colleagues. And that’s the mission I would like to launch and keep on the front burner.

[00:34:49] Dr. JB: I think that some people don’t know how to initiate that conversation.

[00:34:58] Dr. Galanos: That’s very true. That’s why I think every time you give a talk, people resonate with it because I always, I don’t give a talk on anything without talking about how to communicate in that arena. So if it’s about advanced care planning, particularly in palliative care, we very much care about how people talk about it. If we’re going to talk about grief, it’s been plastered all over the professional, as well as lay literature, what to say and what not to say. Of course, it’s a big business because there’s a sympathy card industry that surrounds grief and, there’s social convention and there’s religious convention, depending on your faith tradition, so it’s multilayered like everything else. But I’m hoping if we can talk about it enough– interestingly, last night I was walking out of the hospital with an oncology friend and he had asked me to give my Grief 101 talk to oncology grand rounds, which I’m doing, later this semester.

[00:36:20] And he said, this is the interesting part, “I’m gonna to label it as professional development because we never talk about this and it really does qualify as professional development.” Now, wouldn’t that be an interesting paradigm? If instead of, we’ll only talk about grief when some tragedy happens, it becomes part of your professional development and because you’re gonna experience it both professionally and personally.

[00:36:58] What a great idea that, there you go, you’re just having a casual conversation with somebody you’ve known a long time and a good idea pops out. I wish I had thought of it, but I have to give him credit.

[00:37:17] Dr. JB: You know, and it’s so funny, right? Because you think of oncology, that in a specialty like oncology, why is this not talked about? It almost seems very like taboo, when it’s natural. This isn’t a taboo topic, this is a natural progression, it’s a natural process.  Like I remember I mentioned to you before about when I first started medical school and I was actually really terrified of how do I deal with somebody who’s dying?  And I was a second year at Duke and that probably was the very first rotation. Maybe, it seems like it took place very early during my rotation. So it was probably the first or second that I did with you, and it was a palliative care hospice rotation, and I was able to just kind of like get a sense of all things involved with the palliative care and hospice.

[00:38:21] And I remember vividly riding with the hospice nurses to visit patients, rounding with them in the hospital and just being present. And that was a life-changing experience for me because I realized, and somebody said that, I can’t give them credit, I wish I could, I want to say it was you, who really drove home the whole idea that there is a healthcare worker present for all of your life’s transitions.

[00:38:56] So when you’re, when you come into this world, when you transition from being healthy to being sick, and when you transition from being alive to death.

[00:39:12] Dr. Galanos: Yeah, that’s an excellent point that reinforces everything we’ve been saying. That how do you avoid, you’re not going to avoid anything that’s part of the life cycle if you’re in healthcare and actually it’s a privilege to be in that position. So that’s why I’m still doing what I do because I see it as it matters, and it has meaning, and it’s a privilege to be with people at both their happiest and saddest moments.

[00:39:54] Who provides for the provider, who takes care of the carer? So I think we’re about to embark on a culture change and part of that culture change should be what you and I are talking about. The self-care of the healthcare worker, be they a nurse, a respiratory therapist, I mean, who talks about respiratory therapists? But who’s at the tip of the spear with, it’s the respiratory therapist. And the nurses have a strong union and there’s a bunch of them so if we don’t listen to them, we’re pretty deaf, dumb, and blind.  And I think the most quiet group though is the attendings and that’s where I would like to be of service.  And maybe given my age and seniority  and gender, being a guy, maybe I can help that sub segment of the population that  has been ignored because we think all the older white guys in particular are, they’re fine. “They’ve got money, they’ve got career, they’ve got whatever,” and I think that’s really an enormous fallacy. So, we’ll see what comes next, I’m excited to see what people think is important and should be addressed. I’m also excited to act on what I think is important and needs to be addressed, which is why we’re having this conversation right now.

[00:41:26] Dr. JB: Exactly. I strongly believe that it is okay to not be okay.  And I think, in health care, the only caveat to that statement is timing.  Meaning that if you’re in the middle of a code, you have to keep it together. Right? You have to keep it together because you’re not going to be effective if you don’t. So you compartmentalize and you do what you were trained to do. Afterwards, you step away, or take a pause, take a walk. And it’s perfectly okay to not feel okay.

[00:42:22]Dr. Galanos: Right.

[00:42:23] Well my, my favorite grief book was written by a counselor. I don’t know if she’s a PhD psychologist or Master’s level, but she wrote a great book called “It’s Okay That You’re Not Okay” by Megan Divine. This book came out 2017 or so, and I’ve read a lot of books on grief and grieving in the last two years, but that one by far, spoke to me the best and seemed to really understand that there are certain problems that are not fixable, grief being one of them. And that if we pathologize grief, it’s just going to make people more quiet, feel that much more alone and misunderstood. And I made a slide of that book and I use it in all of my talks because it’s just too important a book.

[00:43:25] Christians all know about CS Lewis and he wrote a very short book, about 80 pages, called “A Grief Observed” and it was about his wife’s struggle with cancer, and then it’s mostly about his grief after she died and it’s very powerful. And Joan Didion wrote a great book called “The Year of Magical Thinking” which she wrote in the year after her husband died suddenly of an acute MI.  The lay literature is probably better than the medical literature in that it really speaks to how much people are hurting and how long it takes to assimilate that kind of grief into your life.  So I, I have, as an academician, I am actually quite grateful that people gave me some books to read and I’m still doing it though, I, I try to cull the literature. I also think that the, there’s some really good books out there and people write these books out of their pain.

[00:44:38] Megan Divine’s husband died in a drowning accident, so very sudden, and Joan Didion’s book is all about her husband and later she wrote a second book, which I’ve not read, that’s about the death of her daughter and her only child. And recently she was interviewed by Time magazine, the very last page of each addition is an interview and the interviewer says to this famous author, “you wrote two books that are very well known about grief, what do you say to people who are grieving?” And she said, “I don’t know. I don’t think anyone knows what to say.” How powerful is that? Yeah. Cause I, I worry about this, that we as doctors, because we think we’re supposed to know what to say or do about everything, that when it comes to grief, we either underdo it, meaning we don’t acknowledge it and we sure as heck don’t talk about it, or we try to fix something that’s not fixable and say the wrong thing, which can also not be neutral, but harmful. And as you adroitly pointed out, how we respond to this crisis, we can either make people feel more alone and misunderstood, or we can let them know that they’re not alone and someone does understand.

[00:46:18] Dr. JB: I think along those lines there is a lot of value to just being present.

[00:46:27] Dr. Galanos: Oh, oh my goodness. Yes.

[00:46:31] Dr. JB: Sometimes you don’t have words or you don’t need words. Right? But just being there.

[00:46:38] Dr. Galanos: You’re singing my choir.  We wrote a paper you know, sorry to be so Duke, we wrote a paper, and I’m the senior author, on top 10 tips of grief and bereavement for palliative care providers, and in palliative care, providers is a broad swath, MDs, NPs, PAs, social work, chaplains , and it got published I’m happy to say, but  I was the one who talked about, I wrote the section on communication. And there’s a table, and it’s short, and at the bottom in a big box says “sometimes there are no words, your physical presence is what the griever for needs.”

[00:47:28]Dr. JB: I think this conversation was needed to happen years ago. But that’s all in the past, all we have is the present, and all we can shape as the future.

[00:47:38]Dr. Galanos: I think your job and your company, it’s going to be an uphill swim. I also think it’s worth the effort.