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When the Doctor is Gone
By Miriam Axel-Lute

 

On Aug. 10, Mary got a call from a friend who had been flipping channels. She’d just seen a news report about a rheumatologist who had committed suicide. She hadn’t caught the name, but said it sounded “Slavic.” That, says Mary, who asked that her real name not be used, “made me think maybe it was my doctor.” It was.

Some of his patients learned about the death of Dr. Patrick J. Mroczkowski, the director of the rheumatology department at Albany Medical Center, on the television news, or by word-of-mouth. Others heard about it when they called to check on an appointment, while others received a call from his office, or a letter from the hospital. Others read the Times Union article about the death of a rheumatologist at Albany Med and paired it with his obituary a few pages later.

Anyone who dies suddenly leaves behind many survivors who experience varying types of grief. In the aftermath of Mroczkowski’s death, some patients feel like their experiences of loss haven’t been taken seriously enough, leaving them isolated in their grief, as well as uncertain about their medical future.

Mroczkowski’s death took leaders at Albany Med by surprise, and they had to craft a response on the fly, while dealing with their own—and their staff’s—grief. “I’ve been a physician leader for over 10 years and I’ve never been confronted with a circumstance like this before, where there’s an abrupt death,” says Ferdinand Venditti, the chairman of the Department of Medicine. Staff members were offered grief counseling, and a memorial service was held last week, as an “attempt to bring some closure to his colleagues,” says Venditti.

Venditti says in notifying patients the hospital “tried to take a more personalized approach” with more “one-on-one communication” than would be usual if a doctor had merely left the practice.

Still, patients have not been assumed to be among those who would be dramatically affected by Mroczkowski’s loss. “The loss of a physician to a patient is not all that unusual,” observes Greg McGarry, vice president of public relations for Albany Medical Center. “At the medical center, a certain percentage of physicians leave every year. It’s just a fact of life.”

It is true that the relationship between doctor and patient is a highly variable one, and it can often be fleeting, distant, or perfunctory. But depending on the physician’s character, the duration of the relationship, and the severity of the condition, it can also be a remarkably close one. “It’s a special, unique, and bonded relationship,” says Dr. Alan Wolfelt, director of the Center for Loss and Life Transition. “While there’s boundaries, it’s one of the most intimate relationships, because people often disclose very personal things.”

For many of his patients, Mroczkowski was one of the rarer cases where the bond was very close. On legacy.com, in the online guest book associated with his obituary, several patients report that he diagnosed and/or solved problems that many other doctors had not been able to figure out. “He was always ahead of the field in thinking about new ways to understand the medical problems of his patients,” writes a former colleague, Dr. David Daikh. Staff and patients alike report that he took extra time with every patient, often running behind because of his commitment not to rush anyone.

But even more common out of the dozens of entries are comments that he was more like a friend than a doctor. “He was like part of my family,” writes Patricia Fish.

“When I was in the hospital on my 16th birthday he came to visit me and even brought me balloons. Dr. Pat you were more than my doctor you were my friend,” writes Phillissia Rouse.

“He gave me hope when I was hopeless. He listened when others did not hear me,” writes Jolene Perkins.

Many of the patients who had relationships like these with Mroczkowski also described their experiences of grief: having their hearts broken, crying for hours, or feeling in shock. “I’ll probably never find another Dr that kind, patient, and loving like he was,” writes Darlene McCarty.

“As I sat waiting yesterday for the Remecade to drip into me I sadly and selfishly thought why did you leave before I got to tell you the next chapter in my mixed up life,” writes Ann Nicholas.

“I miss the guy,” says Mary. “I don’t just miss the care he provided, I miss him. . . He was my primary care physician, and I was pretty attached to him.”

But because they are not within the categories of people traditionally considered to have suffered a close loss, some of Mroczkowski’s patients are feeling isolated in their grief. While some feel that the hospital did enough, and took comfort in the online obituary and comments, others are very much at a loss. “I am operating with no information,” says Jane Knight, a nurse-midwife who had been made unable to work due to the chronic pain that Mroczkowski had been helping her address. She learned of Mroczkowski’s death when she called to check in on an appointment. “It just took my breath away,” she says. “[The nurse] did it very gently, as gently as you can.”

However, “that’s the last communication I’ve had from anyone,” Knight continues, except for a letter from her insurance agency saying they would no longer honor his referrals. She never got the official letter from the hospital, which makes her “very distressed.” “I feel like I have a lot of unfinished business,” she says. “I feel so bad, and I have nowhere to go with these feelings. I feel so helpless.”

“He is the only one who addressed [my chronic pain problem] in an upfront, honest, ‘I’m here to help you, I won’t abandon you’ type way,” she recalls.

“I wish they would hold grief counseling for their patients,” says Mary.

“I think grief counseling is more typically something we think of for employees,” is Venditti’s first response when asked if Albany Med had considering offering counseling to patients as well. “I hadn’t thought of it as something valuable for patients. I’m not sure how we would reach out.” As for the memorial service, “we haven’t precluded patients from coming there,” he said a few days before it was held, but patients were not specifically notified or invited.

It’s not like the hospital had any established practice to go on. “I’m sure they were just totally blindsided,” says Knight, who also has done bereavement counseling for families who have lost a child. “I’ve never read any articles [about dealing with physician death], even in the [grief] counseling literature that I get.” Neither had any of several experts in grief counseling contacted for this article, nor the director of the Committee for Physician Health of Medical Society of the State of New York.

But they all agreed that it was nonetheless important not to leave grieving patients on their own. “Sometimes if a physician dies, patients are at risk of experiencing disenfranchised grief, a lack of social recognition of their loss,” says Wolfelt. “They are then at risk for grieving, but not mourning
. . . mourning is the shared social response.
. . . If you grieve but don’t mourn, you don’t integrate loss into your life.”

If “folks feel they aren’t welcome in a forum where other [mourners] might be, they’re hurt by that, and frustrated their loss isn’t considered important,” says Will Hannah, a bereavement counselor with Community Hospice, Inc. Hannah notes that this can happen for many types of losses, from pets to lovers to ex-spouses or former in-laws.

It’s important to be able to share with other people who have experienced the same type of loss, says Mary Jean Coleman, director of Samaritans Suicide Prevention Center. “To me, the smart thing to do, it would’ve been easy to find out who all his patients were, and just to say we’re going to have a candlelight vigil. . . . [Otherwise,] how would patients be able to get together? They don’t know each other.”

The fact that the death was a suicide, which is often stigmatized and considered inappropriate to discuss, may be contributing to the sense of a lack of resolution for some patients. Though most of them are aware that it was a suicide, from the news or by word-of-mouth, it has never been acknowledged directly by the hospital. McGarry says the hospital is absolutely not at liberty to discuss the cause of death. “The family’s privacy comes first.”

That’s a shame, says Coleman. “It was so public on the news, you’d have to be under a rock [not to hear about it],” she says, noting that relying on rumors can perpetuate a sensationalized version of events. “Our organization strongly encourages people to say that [a] death was suicide. Because that is part of healing, to be able to talk about it. A loss has still occurred, the community lost a great man, why should we not talk about that?”

“If you’re withholding one piece of information, you might be withholding another,” says Frantz of patient reactions to not having a suicide acknowledged. “It’s nice to be able to clear the air.”

Knight says that hearing that it was suicide by word-of-mouth has only made things worse for her. “I’m going through all these scenarios in my head, because I have absolutely no information,” she says. “I just want someone to acknowledge to me, ‘This is what we know about it.’ My feeling is they are trying so hard to protect his confidentiality, and I agree with that, but I do think the patients have some needs also. We sweep suicide under the rug.”

Discussing it is also an opportunity to educate people about the risk factors for suicide (such as having had a suicide in the family), the warning signs (such as suddenly making a will and saying goodbyes or talking about how life is not worth living), and the ways to get help, says Coleman.

Though solid statistics are difficult to find, physician suicide is enough of a problem that national conferences have been held looking for ways to prevent it. One problem faced by many physicians, as well as other professionals, who are struggling with suicidal feelings, is the fear of being labeled as having a psychiatric problem and prevented from continuing in their jobs. “We receive a number of calls to [our confidential] hotline from professionals who have a fear of being found out by other professionals—police officers, firefighters, clinicians,” says Coleman. Along with the Samaritans’ hotline, confidential services specifically for physicians [see resources box] are also available in New York state.

Wolfelt, Hannah, and Coleman agreed that some sort of public mourning event, such as a candlelight vigil, or at the least a support group [see resources box] would be a good idea. “We don’t want to glorify suicide. But we can honor how someone lived,” notes Coleman. “We can volunteer for a suicide prevention hotline, if there’s a need for a channeling of energy somewhere. In itself that’s a healing.”

“Sometimes a memorial service is part of the process of saying goodbye,” notes Thomas Frantz, associate professor of counseling and educational psychology at the University at Buffalo, and an expert in issues of grief and suicide.

And though the hospital is the only institution with access to all the patients’ contact information, such a gathering shouldn’t necessarily have to be the all the hospital’s initiative. “One thing grieving people sometimes need to learn as a survival skill is to ask for what they need,” says Hannah. “[The hospital] may have seen it as an in-house loss of a staff member. The people that are hurt could attempt to say that there’s a group of us that would like to honor this loss.”

“They need to not feel a sense of shame for seeking out support for mourning their loss,” agrees Wolfelt, noting that such a sense of shame often happens in what he calls our “mourning-avoidant” culture, even more so when people are mourning a suicide. “If there’s any way for people in a leadership position [to] recognize that, and create any sort of group,” it would make an incredible difference, he says.

Complicating Mroczkowski’s patients’ experience of loss is fear about the state of their health and the process of finding another doctor to trust.

It was a daunting prospect to reassign Mroczkowski’s large caseload. “Usually [when a doctor leaves] we have months to draft a letter, communicate with patients, get them assigned to new doctors,” says Venditti. “We’re obviously behind immediately in terms of what our normal practice would be.”

An Aug. 12 letter to patients informs them that Mroczkowski has passed away. Since Albany Med has no other rheumatologists (specialists in joint problems such as arthritis), the letter continues, patients should contact their primary care physician or come to the emergency room if they have an emergency. It promises to notify patients as soon as a plan to refer all patients to another rheumatologist are finalized.

During the first couple weeks, the hospital tried to take a triage approach, assessing who had the most urgent need to be seen by someone else, and matching those people up with other rheumatologists. The process hasn’t been easy, in part because there are few rheumatologists in the area, and many of those, unlike the clinic where Mroczkowski worked, don’t take Medicaid. Venditti says that many area doctors have been very generous with their time in helping to meet the sudden need. One has been coming to the clinic one morning per week to see selected patients. But he can see only a fraction of Mroczkowski’s total caseload.

Albany Med has now moved on to trying to help those patients whose needs were less immediate, and the department has begun a search to fill Mroczkowski’s position. “Out of respect, we’ve waited a little bit of time” before starting the search, says Venditti, adding that “given the nature of what he did, and the market for specialists, I don’t anticipate it being easy.” Clinic work is less lucrative than private practice, acknowledged Venditti, and the people who are drawn to it are “a different breed.”

But some folks who weren’t found to have the greatest need feel like they’ve fallen through the cracks of the hospital’s efforts.

Mary says she feels like she’s been left “flapping in the breeze.” She has less than 30 days left on the medications for her rheumatoid arthritis “with no future rheumatologist in sight.” These medications are “not things that can be abruptly stopped,” she notes. Even if she tapers them off, she says, she’d have an incapacitating flare-up. She also notes that Mroczkowski had been monitoring her closely because of potential side effects, including multiple sclerosis, from her medication, and “I don’t have somebody taking care of that now.”

After waiting more than a month and a half for the plan promised in the initial letter, and requesting several times to be seen by the doctor serving the clinic once a week, she says she just got a letter this week “discharging” her from the practice and offering three referrals. Mary had gone to the clinic originally because it was the only place she found that accepted Medicaid, and one of the few that didn’t require a referral from a primary care doctor, leaving her unsure if any of the new referrals will work out. “He treated the ones who were rejected by the other practices in the area,” she says.

“There are so few physicians who understand chronic pain,” says Knight. “That’s where I feel the most loss.”

In the process of transition, patients’ health could also be affected by their grief. “One of the domains of mourning is physical health,” notes Wolfelt. “It could affect the health [problem] they were being seen for.”

“If they have very serious illness, what they’re experiencing could be the most important thing in their lives right now,” notes Frantz.

Frantz says one of the first things that should be done is to address the patients’ fear about what will happen to their medical care. There are two characteristics of fear, notes Frantz: It is always about the future, and always about the unknown. Therefore, “anything the hospital, or anyone, could to do to map out a strategy, a plan for what’s going to happen in the future would be a huge help
. . . and to provide information, as much information as you can responsibly provide.” This could include informing patients about the status of the search process, offering them a timeline within which to expect new referrals and letting them know how it’s progressing, or doing follow-ups to make sure each successfully finds new care.

Frantz suggests bringing patients together for one large meeting, which would accomplish a number of things at once: show patients that the hospital cares, allow the hospital to disseminate information, and allow the patients to talk to each other and do some mourning. Such a meeting could be held by another agency with a hospital representative there, but it would be better if the hospital could do it. “If the hospital is willing to do this,” says Frantz, “I think it would earn them a lot of points in the community.”

maxel-lute@metroland.net


Help Is Available

Have you been having suicidal thoughts? Is someone you know exhibiting signs of being suicidal? Are you dealing with a loss of someone to suicide? There are local resources to help.

Samaritans’ confidential suicide prevention hotline:
689-HOPE (4673)

Samaritans’ Safe Place support groups for survivors of a suicide: 689-0080

Community Hospice, providing free short-term grief counseling and support groups: 285-8150

Committee for Physician Health, Medical Society of the State of New York, providing confidential assistance to physicians, resident physicians, medical students and physician assistants suffering from substance use or other psychiatric disorders: (800) 338-1833

To learn more about warning signs of suicide and helping those who are suicidal, visit:

www.befrienders.org/suicide/warning.htm

www.suicidology.org/displaycommon.cfm?an=2


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