The physician executive and professional grief.

With the introduction of competitive forces and concommitant changes in health care reimbursement programs, physicians are experiencing profound disruption in their personal expectations and career plans. This article proposes that the loss of established professional traditions is no different, in terms of emotional and psychological impact, than the loss of a loved one. Thus, many physicians may need to complete grief work before they can functionally adapt to contemporary realities. The dynamics of loss, grief work, and functional adaptation are discussed, along with recommendations for supportive interventions to help individuals adjust to a competitive health care environment.

Grief is nothing new to a physician. It is a common experience when discussing a terminal clinical prognosis with patients and their family members. The physician as an observer of grief knows its dimensions. But the economic and sociopolitical envirornment in which physicians now practice provokes a kind of "professional grief for many practicing clinicians. Faced with higher and higher malpractice premiums, projected surpluses in various specialties, increasing demands for professional fee discounts, stricter and stricter utilization review processes in medical centers and hospitals, and a more demanding public, physicians perceive themselves as caught up in events over which they have no control. As with the loss of a loved one, these realities invoke mourning' and will require grief work for functional adaptations that will lead to continued professional satisfaction. Research begun in the 1940s' suggests that the perception of loss varies widely among individuals. Almost always it is the perception of loss that invokes grief. Losses may be symbolic and psychosocial, even when they are not recognized or validated by others. For example, managed care plans often require third-party approvals for elective surgery and other treatment. This intrusion in the traditional doctor-patient relationship is perceived by many physicians as a grievous attack on their professional competence and an emasculation of the their role as patient advocates. Such symbolic losses can provoke as real a grief reaction as any tangible loss, requiring significant grief work for effective reorientation.3 Forms of Death The predominant studies of grief invariably have dealt with death and dying. But the same dynamics occur for those experiencing profound symbolic losses. Sudnow identified four types of death (loss) experiences:

Social losses, in which one's roles and

social activities end.

Psychological death, where one's personality

changes, as in the regression

and dependency of aged persons.

Biological (or partial) death through

the loss of a limb or body organ.

Physiological death of the entire organism. The focus of this article is on the first form of death, the experience of loss in one's role and social activity. Most practicing physicians see themselves as having unique positions in society. They are expected to exercise independent professional judgment in clinical situations, consistent with a fundamental commitment to their patients. Physicians pride themselves on having this freedom of expression and action and believe it is essential to their ability to practice high quality medicine. Traditionally, physicians' dedication to the practice of medicine and state-of-theart clinical skiffs has been pursued through a fee-for-service practice style. They are allowed to practice their profession only after a grueling, extensive, and expensive period of training. During their training period, physicians become socialized in the basic tenets of medical practice, a process that characterizes every profession. Accommodation to the contemporary practice environment inevitably provokes a profound challenge to professional values learned during training and reinforced during the retrospective reimbursement period in medicine. For many physicians, this creates a "prisoner's dilemma"-a Hobbesian choice between a compromise in one's professional values and the survival of one's practice. This "no-win" dilemma provokes a sense of loss of a beloved ideal. Physicians become even more grief stricken when other persons accuse them of greed and insufficient self-regulation, overlooking the standard of perfection by which many physicians evaluate themselves.' Models of Grief Freud, in an early work, proposed the classic description of the grief process. He stated that mourning was "a reaction to the loss of a loved person, or to the loss of some abstraction which has taken place of one, such as one's country, liberty, ideal, and so on .... 117 Mourning and grief have subsequently been described as a general process that has stages and phases. Lindeman first used the term grief work" in his landmark study of the tragic 1944 fire at Boston's Coconut Grove.' He described three stages of grief. The first stage, shock and disbelief, includes absolute denial of the loss and an inability to recognize it. The second stage, acute mourning, occurs when recognition of loss is accompanied by an intense preoccupation with the lost image and by loneliness, insomnia, loss of appetite, disinterest in daily affairs, and/or daily weeping. The third and final stage is resolution of the grief process, signaled by gradual reentry into life's activities and reduced preoccupation with the lost image. Another approach to the stages of grief was developed by Bowlby, who also saw it as a three-step process: 1. The urge to recover the lost object. 2. Disorganization and despair. 3. Reorganization. In 1974, Parkes proposed, and Bowlby concurred that a crucial first step was missing: numbness. Out of these efforts, a four-stage model evolved. The first stage is numbness, in the sense of being stunned, with varying degrees of denial. Yearning and searching follows, noted by a strong urge to search for, find, recover, and reunite with the lost image. Anger, restlessness, irritability, disbelief, tension, tearfulness, and wanting to keep a clear visual image of what was lost may be present. The third stage is disorganization and despair, when giving up one's search occurs, often with a sense of depression and lack of purpose. Finally, reorganization develops, in which a break with bonds to the lost object or ideal occurs and a gradual start in new relationships, interests, and appetite begins. Perhaps the most famous stage model was described by Kubler-Ross: 1. Denial and isolation, a defensive sense

of shock to buffer reality that gradually

gives way to less radical defenses. 2. Anger toward the event and its disruptions. 3. Bargaining with authority figures to

forestall the loss or to avoid the grieving 

process. 4. Depression. 5. Acceptance. These stage theories may be seen to include three common elements: an initial period of avoidance of the loss and its facts, meaning, and consequences, followed by a gradual confrontation phase. Confrontation with the reality of the loss is often comingled with denial defenses as one attempts to come to terms emotionally and practically with the loss. During this intermediate phase, very strong emotional reactions occur, with the onset of acute grief. Eventually, these reactions give way to the readjustment phase, when one develops an adequate perspective and a changed identity sufficient to reenter life activities. While the sense of loss may never disappear, it is assimilated so that a reconstructed self-image and life plan can be assumed. This resolution occurs throughout the processes of "grief work." These models are all applicable to physicians as they experience loss in role and social activity in reaction to a competitive, often hostile environment. These losses rarely involve the numbness stage for more than a brief time, unless the grief is for the loss of a practice or a crippling attack on the physician's social or economic status, as happens with malpractice suits. The next phase of grieving, yearning, and searching for the lost role or social activity, is much more common in today's competitive environment. For example, when HMOs first appear on the local scene, well-established physicians may react with anger, irritability, and disbelief. This often takes the form of an effort to circle the wagons" and deny the existence of this threat to their economic well-being and professional authority. They have a clear image of what may be lost and rally together in anger, as if such emotions can actually deflect impending competitive forces. Much constructive energy that could otherwise be directed toward effective response to competition is dissipated in rage and commiseration. In contrast, younger physicians who have been in practice only a short time usually do not share as strong a sense of loss and therefore do not get caught up in this stage. They may support initiatives and the reactive contingencies advocated by the senior group of physicians, but this behavior does not emanate from the same sense of grief. Rather, it is based on their respect for the older physicians as role models. Many physicians do not react at all until they perceive a decline in patients or income. Disorganization and despair occur when it is realized that changes in one's role and social activity have been permanently altered. Physicians behave differently at this stage of grief, depending on age. Those who are approaching retirement typically do not break their ties with their lost images. They accept that the style in which they have practiced for years is altered, but make conscious decisions to ignore or side-step current conditions. A frequent remark from physicians of this age (say 55 or older) is, "I'll continue my practice as I have in the past until it gets so bad I'll quit." These physicians have earned enough for retirement. When they reach that very personal emotional point where required changes violate their professional values, and where the emotional anger consumes professional satisfaction, they plan to leave the practice of medicine to others. Those who go through this event experience it as a bitter personal defeat, virtually as an indictment of their entire career and professional standards. A more subtle social cost is that the departure of these senoir practitioners may deprive the medical profession of its most experienced members, especially those who serve as clinical role models and senior statesmen for younger colleagues. The burden of maintaining the values of medicine then falls primarily on physicians in their forties. This group has very different career priorities. They are typically at the height of their practices, still excited by clinical problems, although encumbered by financial commitments to their children's educations, by practice debts, and by mortgages. Also, they are just beginning to make significant progress toward their retirement funds. Little time or energy is left to take up the mantle of political action and professional adaptation. These physicians often express rage as they see threats to the professional rewards they have only recently acquired. For many physicians in the peak of their careers, the loss is not as much substantiated as it is potentiated. Their anger results from the loss of what should and would otherwise be and is as benumbing as unrequited love. Most private practitioners in their thirties do not have a perception of loss. They hear their older colleagues talking about the losses of automony and quality of care, but it is not as real to them because they came into practice after the economically competitive factors entered the medical scene. In fact, these physicians often perceive nontraditional practice patterns as an opportunity for creating change and progress rather than as a profound loss. Unfortunately, this difference in perception may itself become a source of ridicule and alienation, younger physicians being a minority age segment on the medical staff. Thus, a previously cohesive group of physicians may experience the loss of collegial interactions, above and beyond their individual sense of lost autonomy and respect. The stage of reorganization, where bonds to the losses are broken and there is a gradual adaptation to changed roles and social activity, is a step faced predominantly by midcareer physicians. For the reasons previously cited, they are not in a position to realistically withdraw from practice. Adaptation to the future becomes a painful but ultimate reality, one not to their liking, but nevertheless unavoidable. Grief Work Grief work requires individual engagement in the psychological process of decathexis," a retrieval of emotional bonds and energy from the lost ideal. It is an emotional untying of the ties that bind the individual to the lost image, a literal reversal of the process of commitment". Decathexis is usually accompanied by a general avoidance response. Denial, disbelief, anger, and shock are initial defensive reactions to an overwhelming sense of distress. As Rando states: "It is an emotional anesthesia that serves as a protective mechanism for those who have suddenly been confronted with the destruction of the world they used to know." Individuals may withdraw or retreat into an intellectualization, as if the loss were recognized, even though the emotional impact is being denied. Thus, the ability to eloquently articulate one's emotions can mask an inability to adapt in a functional manner, where energy and commitment are redirected toward feasible changes in practice styles and activities. Confrontation with Reality As reality begins to emerge, a kind of angry sadness"is often mixed with ongoing denial and disbelief. Losses in professional roles and traditional activities induced by the external environment may lead practicing physicians to project their anger on others. For example, as Medicare payments under Part B are frozen, physicians may direct their anger at the President or the Congress and call for political action to defeat legislators who advocate Medicare restrictions. They may project their anger on management or upon physician leaders, as is often seen when utilization review data are used to validate a restriction of clinical privileges. Because many physicians see themselves standing alone as economic entities, the ambiguity and uncertainty existing in these competitive times lead to chronic or intermittent panic. Self-confidence maybe easily shaken, with a heightened sense of professional and personal vulnerabilty. Frustration and futility may also be present. As Randol states: "Many grievers have a profound sense of injustice and disillusionment, feeling that they have played life by the rules but lost the game. The values and beliefs that once were comforting are now useless." Guilt and self-recrimination are commonly felt at this stage. There is a shifting between wishful hope for a restored past and tentative new adaptive activities and thoughts. Relief may eventually be experienced when one fully disengages from previous roles, embracing a new, more functional mindset. But this relief often fuels new guilt, as if the very thought of a more adaptive identity created the brutal conditions that made professional change a necessity. Self-blame is common, especially feelings of betrayal and being a traitor. In almost all studies of loss and grief, such feelings were reported as normal reactions in the confrontation phase. Confrontation may also be manifested by withdrawal, apathy, feelings of abandonment, hopelessness, loneliness, sadness, and disorganization. Difficulty in maintaining work schedules and normal social arrangements is common. Negative self images, transitory and latent, are common." The single most typical reality is an intense yearning. "Grief attacks" may unexpectedly take place, accompanied by a sense of emotional upsurge or mental confusion. Physicians caught up in such circumstances may have concerns about "losing their minds" as they experience uncontrollable emotional swings. This state may occupy varying periods, depending upon the individual. Engle has observed several months to several years in the loss of loved ones, and Lindeman' suggests that blocked confrontation and denial may take more than 15 months and require significant professional intervention. impediments to Grief Work As a result of the increasing numbers of physicians in practice, younger practitioners have deep concerns over limited career opportunities. When they listen to older physicians recall their first few years in practice and the quickness with which they became established, they may find themselves grieving over their inability to do the same. The inability to build a successful practice as quickly as older colleagues may be regarded by younger physician as "socially unspeakable." This attitude then restricts them from adequate ventilation of their fears. Inappropriate comparisons to colleagues who enjoy rapidly growing practices because of being in specialties that are in short supply make it even more difficult to engage in mourning. Normal feelings of doubt maybe replaced by frantic, irrational efforts to make the practice grow through quick decisions and incomplete business plans. Founding members of the leading clinic or community practice may believe that mourning is incompatible with their self-images as "strong personalities."Physicians need to develop appropriate sources of compassion and empathy as an alternative to the traps that invidious comparisons and 'superman" expectations create. Readjustments The healing process, the third stage of grief, begins when new relationships and roles are formed. The emotional energy that has been expended on the lost role or social activity is invested in something else and the ongoing activities of daily life become more focused. This investment does not suddenly happen. The physician moves back and forth from the sadness and guilt of confrontation to a new sense of perspective and professional affiliations. It is important to establish modest, feasible efforts toward the newly defined role so that the grief process does not become arrested, dissipating the retrieved but undirected energy. In this stage, the helpful support of physician colleagues and friends is crucial. Recent research

15,16 now differentiates between helpful and unhelpful support. New affiliations and modest, incremental commitments to the altered role are crucial in the development of new attitudes.11,13,17 Making the transition from the old role to the new one requires seeking out new relationships that reinforce the new identity. For example, a physician's decision to take Medicare assignment and participate in one or more HMOS, when all of his colleagues on the medical staff or in the office refuse to do so, requires an unrealistic amount of effort in this stage. A more appropriate strategy would be to identify respected associates who would support this decision and call for their assistance in dealing with collegial reactions. In the beginning, the readjustment phase is usually slow and fragile. It is strengthened as new role models and supportive friends are found. The need for affiliation and collegial respect among physicians should not be underestimated. "Breaking rank" with colleagues requires a conscious, intellectual, and highly charged emotional exercise that results in an altered relationship with medical colleagues. It often includes the loss of long-term professional relationships and referrals. The decision to abandon local attitudes and engage in activities that are not sanctioned by the informal medical leadership involves risks is as real as those for changing employment in other professions. Anticipating Grief Professional journals and public media have reported economic restrictions in health care for the past several years. Thus, many physicians have anticipated disruption in their career patterns and personal expectations. Fulton and Fulton ton' examined "anticipatory grief" where grieving begins in advance of a predicted loss (as happens in chronic diseases). Rando described four characteristics of anticipatory grief: depression, heightened concern for the loss, rehearsal of the loss event, and adjustment efforts. Anticipatory grief is not to be confused with forewarning of loss. Forewarning does not necessarily lead to understanding, or anticipatory grieving.'8,"' As yet, the dynamics of anticipatory grief are not well established, but the emerging literature describes several major phases." When grief is anticipated, readjustment events can be commenced prior to the loss itself, permitting the loss to be more gradually absorbed. Knowing ahead of time that one intends to run counter to prevailing professional attitudes enables the physician to plan accordingly, and may alleviate the sense of betrayal or ineptitude that is provoked by a sudden loss. The classic study on anticipatory grief conceptualized five elements: 1. Acknowledgement that the loss is inevitable. 2. Grieving through the emotional experience

of loss. 3. Reconciliation, developing a perspective

on the worth of the experience. 4. Detachment, withdrawing the emotional

investment that has been made. 5. Memorialization, developing a conscious

and enduring sense of the loss. Nonetheless, at the time of actual loss, acute grief is present and painful." If the physician engages in excessive anticipatory grief, there may be a decline in the sense of enjoyment previously experienced in practicing medicine, or in the emotional commitment to it. If ambivalent feelings toward one's career are present (as is the case in most career choices), Aldrich has noted, anticipatory grief may stir up feelings of hostility, obstructing post-loss resolution. Physicians may arrest themselves in an emotional state of self-blame, regretting their career choice rather than moving toward a functional adaptation. As a result, anticipatory grief may either be helpful or harmful to the physician, depending on one's ambivalence about being a physician. Establishing a functional equilibrium' between current practice demands and anticipated role changes is a most delicate process. Resentment and jealousy toward those who appear to be free from change (and consequently not experiencing loss or grief)often arise. Lebow identified five adaptive tasks for successfully resolving anticipated loss and grief - Remain involved in ongoing relationships

to the extent possible, with open

communications.

Remain separate from the loss sufficiently

to develop adaptive responses

after the loss occurs.

Cooperatively develop role changes from

the current to the anticipated set of responsibilities.

Come to terms with impending realities

by making practical plans for pre-and

post-loss events.

Take leave of the loss when it occurs by

verbal, nonverbal, concrete, and symbolic

means. Colleagues, partners, family, and friends can be helpful during anticipatory grief. But they may feel stress and anger in their supportive role," with a need to safely ventilate their feelings. If their feelings are unrelieved, they may send mixed messages, being both helpful and expressing anger or stress with their role. Appropriate Support interventions Reach Out Physicians experiencing professional role and social modifications not of their own making often refuse initial offers of support. This should not discourage colleagues, partners, family, and friends. Gentle offers of assistance from colleagues (going to professional meetings or expressing empathy with the grieving physician) are indicators of being helpful. A supportive friend helps mitigate self-recrimination. Nonjudgmental support in maintaining professional relationships is also helpful for physicians. Some physicians are developing support groups to provide a context in which they can express their feelings without fear of disdain or trivialization. Affirm Permission to Grieve Because the resolution of grief requires expression, collegial support is important. If grievers feel rebuffed, either verbally or nonverbally, the grief process may go unresolved. Those who are grieving must be encouraged to do so without guilt or self-reproach. Professional assistance may be appropriate where profound grief is experienced. This assistance can be obtained by individual physicians from local professionals or in medical staff educational settings where a competent facilitator is present to provide guidance to the discussion. Express Empathy, Not Sympathy Randol describes an error that can be made in attempts to commiserate in the pain of the griever. Sympathy may delay confrontation with reality and subsequent adjustment. Sympathy connotes an emotional symbiosis, which often serves to prolong or reincarnate original feeling and emotional states, much like becoming angry or tearful together. For example, the circular complaints one often hears in doctors'lounges are usually sympathetic commiseration rather than empathetic listening or problem solving. Empathy, in which one acknowledges the feelings but does not actually engage in the same emotional state, provides both support and an opportunity for the griever to move beyond overwhelming emotions to a more adaptive phase. Effective listening skills are essential. Otherwise, grievers are likely to engage in gripe sessions that only recreate impractical rage and helplessness. Express Confidence Expressing confidence in the griever's ability to manage the role change is an important contribution. Self- doubts can be minimized when the grieving physician's belief in his or her ability to adapt is reaffirmed. Physicians undergoing role modifications need to align themselves with those who care and have the capacity to provide a kindly, independent affirmation of confidence. Identify Ways To Maintain Health Because physical unless can accompany pent-up rage, fear, or sadness, maintaining physical health is an important parallel task. Inappropriate dependence on prescription drugs may be used to mask the enervation that accompanies grief Colleagues, partners, family, and friends can be especially helpful in paying attention to the grieving physician's need for rest and restoration. Realigning an on-call schedule, sharing in patient caseloads that become overwhelming, or increasing attention to exercise and nutrition may all be helpful. Those trying to help the grieving physician can provide support by listening and validating the new role and its relationships. They can clarify and sort out what is to be retained and what is to be given up. They can share perspectives and metaphors that they have found helpful in similar situations but should stop short of sympathetic denial of the need for readjustment. Lehman points out that prescriptive advice, telling a griever what to do or exhorting him not to grieve, is upsetting and often offensive. With well-developed listening skills, expressions of interest, and concern, a variety of alternative perspectives that assist the griever to conceptualize the necessary changes can be provided. Conclusion Ironically physicians are exposed throughout their careers to death and dying. Frequent observers of grief, they are often neither prepared nor supported for applying these dynamics to professional adjustment when experiencing symbolic or substantial role changes. Professional assistance through support groups and from caring colleagues, partners, family, and friends seems largely undeveloped in the medical profession, even though changes now under way are as traumatic as those called for in the Flexner Report of 1910. The competitive forces now at work disrupt longstanding precepts of medical practice. They may leave the individual physician vulnerable, angry, unsure of the future, and resentful of what is happening to the profession's traditional role. Grief work is an important tool in coping with the realities now affecting medical practice. The ability to resolve professional grieving due to transitions in contemporary health care is an important task for physicians and other health care providers. Even though this article has described the psychosocial phases of grief work, individual physicians will develop unique personal solutions to professional grief. The task is not to prescribe a generic solution but rather to facilitate functional adaptation to which physicians can commit their personal energy and professional talent. While collective strategy and professional policy is an appropriate mechanism for managing large-scale transition, as within industries and entire professional groups, individual physicians need supportive empathy to determine the most effective resolution for their professional grief.