Introduction

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In 1941 Lindemann suggested that bereaved people need to separate from the memory of the deceased, readjust to the environment in which the deceased is missing, and form new relationships.¹ Bereavement carries appreciable morbidity and mortality. ^{2 3} Support for bereaved people had been proposed⁴ as there is risk of depression,⁵ prolonged distress,⁶ and persistent or chronic grief.⁷ Some studies have suggested that bereaved people benefit from involvement of family doctors. ^{8 9} Contact is at least appreciated.¹⁰ Up to a quarter of patients have suffered unresolved grief before the onset of their medical problems.¹¹

What are general practitioners doing about patients' bereavements? Death registers have been suggested¹² and, if organised by health authorities, would provide a more efficient system of notifying deaths to practices.¹³ Charlton and Dolman recommended that practices appoint a key worker who would make contact with bereaved people to express sympathy and enable them to express emotion.¹⁴ In South Thames region, two fifths of practices routinely offer contact with bereaved people.¹⁵ However, there is a lack of research evidence about the efficacy of bereavement management and the role of the general practitioner. In addition, no definition exists of good practice, and there is a risk that general practitioners may medicalise a social experience to which they would then have to respond.^16-18

We were interested in the beliefs and attitudes of general practitioners to death and bereavement among their practice populations, what they did, and how they explained their actions. The study set out to investigate general practitioners' perceptions when notified of a death in practice, to explore doctors' accounts of their relationships with their patients in the context of bereavement, and to explore areas of concern to general practitioners in managing themselves and bereaved patients.

Participants and methods
As this was uncharted territory, we decided to use qualitative methods to explore the ideas and experiences of the study population. ^{19 20} One of us (EMS), a general practitioner with an interest in bereavement, undertook six pilot interviews with general practitioners during 1996. Doctors' ideas and concerns about bereavement were identified. The main study was of general practitioners practising in the London borough of Redbridge. We used a semistructured questionnaire and recorded interviews on to audiotape for transcription. We analysed the interviews using a grounded theory approach²¹ with Atlas Ti qualitative research software. The study was approved by Barking and Havering ethics committee.

	Results

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Of 45 general practitioners sent letters of invitation, 25 agreed to be interviewed, a response rate of 56%. Compared with the total population of general practitioners in Redbridge, there were more women in the sample (36% v 31%), fewer non-white doctors (48% v 55%), and fewer singlehanded practitioners (32% v 44%). The mean number of years in practice was 15.3 (SD 8) years. Twelve had had formal vocational training, and 14 completed their undergraduate training in the United Kingdom. Ten had membership of the Royal College of General Practitioners. The box gives the themes identified from the transcripts.

All but three doctors described fears of making mistakes and feelings of guilt and self blame when their expectations of the clinical course of illness differed from reality. One said:

It was a classic: no history, a fit man (with) epigastric pain. Went off and had a heart attack a couple of days later, and I felt awful.

Some expressed the view that if there was a perceived error it was important to make contact in order to be seen to be taking responsibility. Some felt confession to be important as part of the empathic process. They also perceived the error as a learning experience. One doctor said:

You feel better. They learn something from it, you learn something from it. The relatives feel better. You should tell junior doctors that it is better to front it out.

The doctor-patient relationship was also felt to potentially protect general practitioners:

Because they know us better than hospital doctors this tends to negate the anger. The hospital is just the hospital. They have known us for years.

Approaches in hospital and general practice
Twenty of the 25 doctors described a difference they perceived between general practice and hospital medicine. One said:

There is a need to teach medical students that in general practice things are often very fuzzy, and that the GP sees people over a very long time. In general practice you can have rows with someone yet still have a relationship with them.

Influence of medical training and personal experience
Only three out of 25 doctors mentioned that vocational training had influenced their bereavement management. Most doctors felt that their attitudes and beliefs were based on personal rather than professional experience. Twenty three felt ill equipped by their medical school training:

At medical school nobody tells you that you are not treating a disease. You are treating a person who has come to you with a problem.

I was brought up in Tanzania, and there was a family doctor who was a real family doctor. He knew everyone in the town. That was it. I try to do the same.

As you grow older, it is from the personal experience of bereavement that you begin to appreciate more of how people feel and what they need. When you are younger you behave as if you've got to help the relative deny that the deceased existed. That attitude changes as you mature.

Approaches towards contacting bereaved patients
Most doctors felt that general practitioners had a responsibility to make some sort of contact with bereaved patients, with 17 out of 25 doctors specifically discussing making a contact. All subjects related this to the doctor-patient relationship. If this was strong, then contact was more likely:

If it was a patient I had been looking after for some time then I would follow up with a post-bereavement visit either immediately or within a couple of weeks after the death.

We ring up sometimes ... occasionally we write. That's about it, but if we've been involved with the death, we usually go round.

I've been to their house many times, but this time I am not a medical man and my role as a medical man has finished. So I am just a human being and my feelings are those of a human being.

Doctors' own sense of loss
Occasionally a doctor reported experiencing personal grief at the loss of a patient because of a process of identification with the patient. One said:

I can see my own parents in some of my patients. I find myself attached to them trying to look after them the best I am able to in the last few weeks of their lives. I nurse them as I nursed my parents.

The longer I have been in practice the more painful the loss of my patients, particularly as I have known them for most of my professional life.

	Discussion

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This study explored the ideas and beliefs of general practitioners about death and bereavement in patients. The use of interviews allowed greater exploration of ideas and feelings than would have been possible by quantitative techniques. Interviewees' comments were taken at face value.

The study has the following weaknesses. The sample group was small, and some of the ideas may not be generalisable. In addition, the study population was selected purposely. It comprised only doctors who agreed to be interviewed and was not precisely representative of the total population of practitioners in Redbridge. Those who refused may have different opinions. The interviewer was a general practitioner and was able to establish good rapport with respondents. This may also have been a source of bias.

Guilt, blame, and diagnosis of serious disease
General practice carries a high risk of mental illness for doctors.²² All but three doctors in this study had felt guilty about issues relating to the death of patients. Such feelings of guilt seemed to be based on the expectation of not making a mistake. Medical school education, with its emphasis on the biomedical model and appearing to "get it right," left some general practitioners with a feeling of inadequacy. There is ample evidence of stress among general practitioners, and this is one of the likely causes.²³

Contact
If general practitioners were intensely involved with the dying patient, they considered a home visit, telephone contact, or some other contact with bereaved relatives appropriate. When the relationship was less intense, or if the death occurred outside the borders of general practice, contact was less likely. Visiting, telephone, cards, and letters were all used. Although professional expressions of sympathy and condolence were offered, there could also be a personal element from the doctor. The doctor was also one of the bereaved, having lost a patient and a relationship, and some needed to grieve and express emotion.

	Acknowledgments

We thank the participating general practitioners in Redbridge who gave so freely of their time to make this research possible. This study was presented by EMS in partial requirement for the master of science in general practice at UMDS Guy's and St Thomas's Medical School, University of London.

Contributors: ES conceived the original idea, developed the questionnaire, organised the sample, undertook the interviews and analysis and developed a dissertation from which this paper arose. LR supervised the research, helped to clarify ideas and procedures, contributed to the analysis, and gave helpful criticism in the preparation of this paper. The paper was written jointly by both. ES is the guarantor.

	Footnotes

Funding: EMS received financial support from the Scientific Foundation of the Royal College of General Practitioners to defray project costs and from the Department of Health for locum costs under the extended study leave programme. In addition, generous support was provided by the Barking and Havering Health Authority.

Competing interests: None declared.

	References

Top Abstract Introduction Results Discussion References

1.	Lindemann E. Symptomatology and management of acute grief. Am J Psychiatry 1944; 101: 141-148[Free Full Text].
2.	Murray Parkes C. Effects of bereavement on physical and mental health: a study of the medical records of widows. BMJ 1964; ii: 274-276.
3.	Rees DW, Lutkins SG. Mortality of bereavement. BMJ 1967; iv: 13-16.
4.	Estok P, Lehrman A. Perinatal death: grief support for families. Birth 1983; 10: 17-25[Medline].
5.	Clayton P. Mortality and morbidity in the first year of widowhood. Arch Gen Psychiatry 1974; 30: 747-750[Abstract/Free Full Text].
6.	Tudiver F, Hilditch J, Permaul JA. A comparison of psychosocial characteristics of new widowers and married men. Fam Med 1991; 23: 501-505[Medline].
7.	Byrne GJA, Raphael B. A longitudinal study of bereavement phenomena in recently widowed elderly men. Psychol Med 1994; 24: 411-421[Medline].
8.	Pasnau RO, Fawzey FL, Fawzey N. The role of the physician in bereavement. Psychiatric Clin N Am 1987; 10: 109-120.
9.	Wadland WC, Keller B, Jones W, Chapados J. Sudden, unexpected death and the role of the family physician. Fam Systems Med 1988; 6: 176-187.
10.	Dangler LA, O'Donnell J, Gingrich C, Bope ET. What do family membersexpect form the family physician of a deceased loved one? Fam Med 1996; 28: 694-697[Medline].
11.	DeVaul RA, Zisook S, Faschingbauer TR. Clinical aspects of grief and bereavement. Primary Care 1979; 6: 391-402[Medline].
12.	Berlin A, Bhopal R, Spencer J, Van Zwanenberg T. Creating a death register for general practice. Br J Gen Pract 1992; 43: 70-72.
13.	Stacy R, Robinson L, Bhopal R, Spencer J. Evaluation of death registers in general practice. Br J Gen Pract 1998; 48: 1739-1741[Medline].
14.	Charlton R, Dolman E. Bereavement: a protocol for primary care. Br J Gen Pract 1995; 45: 427-430[Medline].
15.	Harris T, Kendrick T. Bereavement care in general practice: a survey in South Thames Health Region. Br J Gen Pract 1998; 46: 1560-1564.
16.	Woof WR, Carter YH. The grieving adult and the general practitioner: a literature review in two parts (part 1). Br J Gen Pract 1997; 47: 443-448[Medline].
17.	Woof WR, Carter YH. The grieving adult and the general practitioner: a literature review in two parts (part 2). Br J Gen Pract 1997; 47: 509-514[Medline].
18.	Woof WR. The future of bereavement care in British general practice. Eur J Cancer Care 1997; 6: 133-136.
19.	Britten N, Jones R, Murphy E, Stacey R. Qualitative research methods in general practice and primary care. Fam Pract 1995; 12: 104-114[Free Full Text].
20.	Strauss A. Qualitative analysis for social scientists. Cambridge: Cambridge University Press , 1987.
21.	Muhr T. A prototype for the support of text interpretation. Qualitative Sociology 1991; 4: 349-371.
22.	Howell J, Fisher F, Morgan DR, eds. Stress and the medical profession. London: BMA, 1992.
23.	Rout U. Stress among general practitioners and their spouses: a qualitative study. Br J Gen Pract 1996; 46: 57-60.
24.	Bateman B. Differentiating illness from disease: a dilemma for general practitioners. Aus Fam Phys 1996; 25: 1687-1689[Medline].

(Accepted 30 April 1999)

Commentary: Use of personal experience should be legitimised

David Jewell, general practitioner. 

Department of Epidemiology, Canynge Hall, Bristol BS8 2PR

Saunderson and Ridsdale are correct in saying that conclusions about general practitioners' attitudes to bereavement can be obtained only by qualitative techniques. Even if the ideas are not generalisable, the study carries validity in terms of the true feelings of the interviewed doctors. It also echoes two familiar truths of general practice. On one hand, personal care can not only bring unquantifiable benefits to patients and their families but also give deep and long lasting satisfaction to the doctor. On the other hand, equally familiar is the guilt of doctors who feel they are not practising the "proper medicine" that goes on in hospitals. It is surprising and sad to discover that this canard still persists.

The authors conclude that doctors rely more on their own experience than on formal teaching from medical school when dealing with death and bereavement. It would be tempting to conclude that here is a subject crying out for inclusion in the undergraduate medical curriculum. Thank goodness, in today's reformed educational world¹ more thoughtful counsels will prevail. To regular readers of the BMJ's Personal View column this finding is also not a surprise. Every few weeks a personal account of illness in themselves or a close relative describes doctors learning from the experience of suffering. Yet my own contact with students suggests that most of them come to university already equipped with this understanding of suffering, based on the experience of friends or close relatives.

Our lived experience, or that of close friends and relatives, is probably one of the most valuable resources, helping us to a more immediate understanding of human illness than any medical textbooks, or even a study of narrative, can do. Perhaps undergraduates in the first years of study know this instinctively, or perhaps they simply have nothing else to guide them. However, what traditional courses teach them, if only implicitly, is that this knowledge is not to be trusted. As Platt put it so eloquently, "The first staggering fact about medical education is that after two and a half years of being taught on the assumption that everyone is the same the student has to find out for himself that everyone is different, which is what his experience has taught him since infancy."²

What is needed is a rigorous approach to using life experience. We should start by legitimising it as a valid source of information. We need then to explore the pitfallshow and when it misleads. Like every drug, operation, intervention, technique, instrument, etc, it carries risks as well as benefits. So while we are making its use explicit we may be able to help doctors learn the limits of its usefulness. The message to students and doctors needs to be not only "trust your experience" but also "know when to trust it and when not to," and even, most difficult "be confident about synthesising what you know from experience with your knowledge of biomedical science." What we want are graduates who, as the participants in a similar study in 20 years' time, will reply confidently: "One of the things I learnt in medical school was to rely on my own experience with these kind of problems."

	References

1.	General Medical Council. Tomorrow's doctors. Recommendations on undergraduate medical education. London: GMC , 1993.
2.	Platt R. Thoughts on teaching medicine. BMJ 1965; ii: 551-552.