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Colin Murray Parkes, a well-known British psychiatrist and hospitalist movement leader, once wrote “The pain of grief is just as much a part of life as the joy of love; it is, perhaps, the price we pay for love, the cost of commitment.” Winnie the Pooh, another great psychiatrist, concluded, “How lucky I am to have something that makes saying goodbye so hard.” In her thoughtful essay, “It’s Not Me It’s You,” medical student Melissa Hill insightfully observes that while medical education pays a lot of attention to learning how to form connections with patients, less care is given to dealing with the challenges of depth relationships in medicine, especially when it comes to saying goodbye. I applaud Hill’s call for better preparation of learners regarding how to navigate the complexities of the doctor-patient relationship. Although medical training rightly emphasizes patient-centered care, medicine is fundamentally relational, which means that physicians must attend not only to their patients but to themselves and the dynamics that exist between them.
The example Ms. Hill focuses on, saying goodbye to someone who is part friend, part teacher, is a critical one in healthcare: patients die, patients change or lose insurance, patients (and doctors) move away. Sometimes, less happily, patients withdraw from a practice or are discharged by their physicians. All these situations ideally require a conscious letting go, yet too often physicians avoid their own loss and grief (as well as other complicated emotions), and simply move on to the next case. The key lies not in avoiding connection in the first place (a self-protective but ultimately dysfunctional strategy that contributes to burnout), but in doctor and patient taking time to overtly express to one another all that was meaningful and valuable in the relationship, acknowledge the sorrow of an ending, and, as Pooh suggests, focus on the gratitude that arises from having had such a rich, fulfilling bond. Having the courage to walk through the loss of a relationship makes it easier to appreciate its gifts. This is not necessarily an obvious or an easy process, and medical education curriculum should address ways of helping students foster this essential skill.