One mid-summer's day

Kathy K L Tsim 詹觀蘭

Summer is at long last upon us! July should have been a month full of sunny lazy days. But, alas, the opposite was true. It all began well with the high profile Live 8 concert enlivening millions in the world, running alongside the negotiations in Glasgow among the wealthy G8 nations: all with the aim of providing aid to help relieve the suffering of the poor. However, amid all these good intentions, were the horrible unimaginable bombings, which was taking place in London. A sunny summer morning suddenly turned black for many families whose loved ones were caught in the terrible act.

As we waited and watched the disaster unfold, we as family physicians are posed in anticipation as to what role we might be called to play as the unfortunate victims' family members come to seek help. Help with finding a way to cope and to deal with this sudden loss. In no other specialty in medicine, perhaps with the exception of palliative care, do doctors have to come face to face with the reality of loss and grieving as the family physician.

Grief itself has many common psychological, physical and behavioural manifestations, but people experiencing the sudden death of a loved one are at a greater risk of experiencing a more pronounced and prolonged grief reaction than those who are waiting to die.¹

We as family physicians are placed in a key position to help them with the difficult task of walking this road. The most important thing to remember as their care provider is that grief is only a process and not the endpoint. The goal of grieving is not to get the person to forget about the loss, a commonly stated goal of survivors; but rather, to remember the decedent, understand the changes created by the loss, and determine how to reinvest in life.²

The language to be used with families during these times of devastating loss is important. Language has the potential to either intensify suffering or enhance family experience of grieving. What is the most harmful is the silence that can surround this situation and hinder the grief process.³

Of course, the most important initial step is for the sudden death to be acknowledged by the family and their family physician. This is made easier for the family if there is already a strong doctor-patient relationship with the family doctor.

The formation of a trusting doctor-patient relationship, like all good things in life, takes time. It is through attending to the often minor ailments that this relationship is gradually developed.

Research has shown that both patients and their family physicians particularly value such a personal relationship for more serious or psychological problems. However, whether patients have a personal family physician is associated with their perception of its importance.⁴

In a place such as Hong Kong, where the importance is often placed on seeing quick results, whether one is recovering from a viral illness or is in a business transaction, time is a precious commodity to have. However, ultimately it is time that is not only needed in the important process of forming a strong personal doctor relationship but also when it comes to the slow but long term healing of certain illnesses. The public hence needs to be educated with regards this and the ill-effects of doctor shopping, self-diagnosis and purchasing medication over-the-counter.

As doctors we also have a role to play in encouraging such a personal doctor-patient relationship. We need to have the time available and the patience to talk with the patient who is consulting us.

We need to take a genuine interest in the welfare of our patients. This in fact is part of our duty of care.⁵ We also need to develop not only communication skills but also a sense of having a healthy suspicion for our patient's hidden agendas. Psychosocial issues are more often left out in any consultation. Active steps should be taken in our daily practice to encourage the voicing of these agendas.⁶

Increasing patient participation in any consultation means, again the need for extra time to be made readily available. This however, is often lacking in the reality of a busy doctor's surgery. However, it has been shown that longer consultations are associated with a range of better patient outcomes and better doctor-patient understanding. This results in better patient and doctor satisfaction as well as better patient enablement.⁷

This is never more important than in cases of sudden death. By sensitive open ended questions to "test the water", we are offering the patients an opportunity to open up to the process of grieving. Once the floodgates are opened it is important to let the patients know that they are in a safe environment to talk about their feelings.

The stages of grieving that the patients experience are often not as clear cut as in the textbooks. One stage does not necessarily follow on from the other. The patient can often experience a pot-pourri of all the stages at any stage of their walk. It is the doctor's task then to aid them and help them define what stage they are at. We act as facilitators but the walking will need to be done by them. Help can often be enlisted via other primary-care team members, e.g. clinical psychologist, social workers, and of course other family members.

By practising the skills of communication, active listening, rapport building, empathy, family physicians can aid the majority of the bereaved to reach the goal of acceptance and moving on.

Only for those who are lagging behind or who are still experiencing symptoms, the prudent use of antidepressants and anxiolytics becomes necessary; with a strong emphasis on maintaining a close patient contact. As doctors for the family we hope for a "cure" but will often settle for being a long term companion to the family as they go through their journey of life and suffering. We are, after all, as our title infers, the family's physicians or family physicians.