Returning to training following a bereavement

The loss of a loved one is one of the toughest challenges we go through during our lifetime. Balancing the grieving process with working life can feel nearly impossible and sometimes the best course of action is to take some time away from work.  

Working within the NHS comes with unparalleled challenges and a Junior Doctor can have upwards of 13 years before fully qualifying. Training is uniquely stressful with high stakes, long hours and immense scrutiny from supervisors, the Trust and the general public. When death is constantly on your mind, there is no working environment more triggering than a hospital; the constant exposure to life-threatening situations weighs even more heavily when recovering from your own loss.

Making the decision to take time out from training is never an easy one, however space from the clinical environment can make all the difference when processing the loss of someone close to you. It allows you to seek support without compromising your work and gives you the opportunity to start to heal before recommitting yourself to healing others. However, making the transition back into comes with its own challenges.

Irrespective of grief, returning to training is one of the most challenging periods in a doctor’s entire career. Doctors are so often taken for granted: whilst a patient in critical condition doesn’t have much understanding for any crisis in your confidence, clinical decision-making is impossible without it. Work by Health Education England Work found lack confidence in clinical knowledge and skills, low self-perception of capability and an inability to adjust to new personal circumstances in the workplace to be the most common concerns for Junior Doctors in coming back into work. These concerns are universal across specialities and level of seniority in training; those entering their final years of training are just as affected by self-doubt as those returning in the early stages.

The hospital can stir up long-passed pain. Even those feeling relatively free from grief can find transitioning back emotional, particularly when encountering – even treating – the very conditions that took the lives of their loved ones. The stiff upper lip prescription is especially tough to swallow in such situations.

Doctors are perceived as figures of strength with personhood exchanged for the stethoscope. Trauma, and any psychological distress associated, is highly stigmatised in general but even more so for those in such positions of authority. Though it is the duty of educational supervisors to ensure any returnees are fit for practice, the intense spotlight that accompanies returning to training can be incredibly anxiety-inducing. Though patient safety must be safeguarded, it is no surprise that doctors often feel their own is secondary.  

Challenges unique to returning to training after a bereavement:  

1. Exposure to the conditions responsible for a loved ones’ death
2. Fear of judgment from colleagues – of appearing ‘weak’, for example
3. Stigma associated with mental health difficulties – PTSD, depression, anxiety etc.  
4. Post-bereavement hallucinatory experiences at work
5. Financial strain (particularly if co-dependent on the deceased’s income)
6. Possible breakdown in child care
7. Difficulties scheduling ongoing counselling with unreliable shift work

Mourning doesn’t have a set timeline and those returning after a bereavement often experience far longer adjustment periods than other returning colleagues. Though perhaps not capable of accelerating the grieving process, many resources are available to you for support during time away and during return. Remember, recovering from loss isn’t your responsibility alone. Your safe and successful return to training is as much a responsibility of your Deanery as it is you.

Tailoring return to practice – what your Deanery can do for you:

Organising ‘top-up’ training and CPD-approved learning during time away and return

Though formal ‘Keep In Touch’ (KIT) days are primarily only available to those on paternity leave, opportunities do exist to ensure you feel prepared to return to the workplace after time spent away. Online resources are incredibly valuable in this; see below some relevant examples taken from the British Medical Journal Learning Portal.

• http://learning.bmj.com/learning/module-intro/career-break.html?moduleId=10060748&searchTerm=“career”&page=1&locale=en_GB
• http://learning.bmj.com/learning/module-intro/time-management.html?moduleId=10060437&locale=en_GB
• http://learning.bmj.com/learning/module-intro/resilience.html?moduleId=10060244&locale=en_GB

Contact your Deanery to enquire if any in-person learning is available (such as ‘bootcamps’ or accelerated learning schemes’) or if a KIT day could be arranged during your time away. Additionally, consider enrolling on London School of Medicine’s ‘Springboard’ Course. This is one-day course offered twice each year for those looking for both practical and pastoral support prior to returning to training.

Provide a designated mentor/coach

In 2016, The Advisory, Conciliation and Arbitration Service (ACAS) agreement within the Junior Doctors Contract committed the Secretary of State to fund mentorship for junior doctors when returning to training. Though this service is not yet universally accessible, it is worth contacting your Deanery as to whether a Senior Consultant with experience of bereavement during training could be made available for advice and ongoing support. This may also be available in a group setting.

Arrange a supernumerary period or phased return

This refers to a period of intensive and supervised practice, including a variety of focused learning activities under direct observation. Contact your educational supervisor to see if any such opportunities exist, perhaps alongside other returners. Such support will be most beneficial on your first on-call rotas. It is important to be honest about your needs in this, particularly the level of intensity you need in this support. Asking for help saves your confidence and, in turn, helps you keep saving lives. It may also be worth considering Less Than Full Time Training – at least initially – upon return.

Ensure first patient lists are as straightforward as possible, minimising risk of coming into contact with conditions associated with the bereavement.

The life if a junior doctor is notoriously changeable, with every patient seemingly more unpredictable than the next. However, if you feel comfortable doing so, make sure your educational supervisor is aware of the nature of your bereavement and see whether your patient lists can be tailored to your needs at this time.  

Signpost to centralised support in local HEE office

Check in to locate your local HEE office.

Additional resources for supporting bereaved doctors:

• Support Around Death
• Tea and Empathy
• Campaign Against Living Miserably
• Doctors’ Support Network
• DocHealth
• NHS Practitioner Health Programme: Occupational Mental Health Services
• SANE
• British Association for Counselling and Psychotherapy

Case Study: SJ

I had a year off work following the death of my second daughter (she was stillborn at full term and I was entitled to my full maternity leave). I am a paediatrician and had enormous concerns about returning to work; a massive dip in confidence, concerns about dealing with babies and their families, worries about dealing with child death at work, worries about not having enough time to continue grieving for my daughter, and worries about being overwhelmed, panicking or bursting into tears at work.

I returned to working in the hospital where my daughter had died and even though this was my choice, to begin with I couldn’t walk into the hospital without shaking!

Some difficulties I experienced first hand:

• Anxieties about working with babies and children and dealing with child death.
• Word-finding difficulties and slowness.
• Worries about people judging me.
• Less time for grieving.
• Reduced concentration and motivation.
• Lack of confidence.
• I found small talk difficult and irritating.
• Exhaustion.

“My experience was that medical staffing made everything more stressful for me – no one seemed to want to take responsibility for my employment. They also didn’t pay me for several months which added a lot of unnecessary stress at what was a hugely stressful time anyway for me.  

[To improve official support] I think that having lead employers and lead occupational health services for doctors in training would help massively; it really made me feel like no one wanted me or would take responsibility for me. Having a choice of which department I returned to did give me some control over my return (it happened to be the department my Training Programme Director (TPD)  is in, and this also gave me a degree of security).

However, my TPD was super-supportive and always ready to help me. I accessed support from the Professional Support Unit and Medic Support (the local equivalent of the Practitioner Health Programme). I had a phased and supernumerary return which was facilitated by occupational health. I also found the Facebook peer support group “Tea & Empathy” invaluable.

I spoke about my experiences at the Health Education England co-design event in August 2017 – my talk can be found here.”

Major life events often come at the least convenient times and the death of a loved one has impact far beyond your career. Prioritising your well-being is not an act of selfishness; there is no weakness in taking time to recover from loss and asking for help in return. This time away provides an opportunity to develop resilience and deepen empathy. Though difficult to appreciate in the depths of grief, it is important to remember characteristics such as these are the makings of the best possible doctor.

‍