EP184: Navigating Grief: A Conversation with Dr. Tony Subtil

Navigating Grief with Dr. Tony Subtil: Acceptance, Processing, and Adjustment

In this episode of The Girl Doc Survival Guide, Christine explores the topic of grief with Dr. Tony Subtil, a Clinical Associate Professor of Pathology at the University of British Columbia and author of the textbook Diagnosis of Cutaneous Lymphoid Infiltrates: A Visual Approach to Differential Diagnosis and Knowledge Gaps. Dr. Subtil shares his personal experiences with grief, discusses the common misconceptions physicians may have about it, and provides insights into understanding and managing grief as both a personal and universal experience. They touch on the importance of accepting, processing, and adjusting to loss, and highlight the value of self-compassion, therapy, and community support in the grieving process. Dr. Subtil also talks about integrating new activities, like pottery, and shares his perspective on grief as a form of praise for the love and connections we experience in life.

00:00 Introduction to Dr. Tony Subtil

01:01 Personal Anecdotes and Early Life

02:09 Understanding Grief: A Personal Journey

03:29 The Broader Scope of Grief

04:48 Coping Mechanisms and Healing

06:22 The Role of Community and Support

07:00 Accept, Process, Adjust: A New Paradigm

10:23 Practical Tips for Processing Grief

13:04 Balancing Career and Grief

13:38 Final Thoughts on Grief and Love

Transcript

Christine Ko: [00:00:00] Welcome back to The Girl Doc Survival Guide. Today, I'm very pleased to be with, and I will say his full name once, Dr. Antonio Subtil Deoliveira. But I call him Tony Subtil, Dr. Tony Subtil, who is currently a Clinical Associate Professor of Pathology and Laboratory Medicine at the University of British Columbia, as well as an anatomic pathologist at the Royal Jubilee Hospital. Dr. Subtil is trained in both hematopathology as well as dermatopathology. He has a special interest in cutaneous lymphomas and has given hundreds of invited lectures at regional, national, and international meetings. I know Tony because we worked together at Yale, and he was my neighbor. The office right next to mine was Tony's. And so it's always fun to show him cases and sometimes just chat about random things and admire his fashion. It's fun to talk to Tony again. 

Tony Subtil: Hi, Christine. Thanks for having [00:01:00] me. Yeah, I miss you. 

Christine Ko: I miss you, too. Can you share a personal anecdote first? 

Tony Subtil: Sure. I was a teenager when I was accepted to medical school, 16 years old. I'm from Brazil originally, and down there, you start med school right after high school. I was really young. I didn't think I was too young to be in med school, but looking back I can see that it was a bit too soon to start up. I'm actually going to my 30 year med school reunion this year. It's hard to believe 'cause I still feel young, but it's hard to believe that I've been a doctor for three decades. My dad passed away when I was in the last year of medical school, and my mom passed away recently, so I was thinking about how these three decades have been bracketed by losing both parents. Something that has been on my mind lately. 

Christine Ko: Yes. I'm sorry to hear that. Yeah. You had told me about your mother passing and how grief has been really hard. [00:02:00] We talked just by text really about it would be great to talk about grief together and what you've learned. 

Tony Subtil: Yeah. To me it's interesting because before experiencing grief myself, I had some assumptions about it, and I think for physicians it's often shocking when we go through grief personally 'cause, in training, in practice, there's just so much death, or severe disease that we witness. And it feels sad, we don't want that happening to our patients, but it's a reality of medical practice. We just have death and severe disease happening. So we might have this assumption that we understand grief ' cause we, we are witnessing grief in our patients, but going through grief personally, that's completely different. That's a completely different experience. It feels different. Before experiencing grief, personally myself, I had this assumption that emotionally it would feel like falling off a cliff. The sudden drop and then slowly you get [00:03:00] back up from that valley. But for me, after losing my parents, it felt more like an EKG tracing, ups and downs, more downs than ups actually, or it was irregular, random, more afib, or it felt like Vtach, at times. To me, that was a surprise, that it wasn't just like this deep sadness, but it was more the whole range of emotions could happen in a day. Sadness, laughter, and joy. I definitely felt different, going through that personally. Another surprise for me is that I thought of grief as about big things. Death, divorce. But I think grief is about any change, any loss, so even smaller losses, they can induce a level of grief that we might not acknowledge, whether it's a health problem in yourself or a close family member. Even moving, aging, has its own grief. Retirement can produce grief in some people. So it's not just big things like death and divorce that can cause grief. [00:04:00] Any significant loss can do that. So for me personally, I moved a lot doing training. Med school in Brazil, my internship in Miami, residency in Missouri, fellowship in Minnesota, another fellowship in Atlanta, first job in Connecticut, and now in Canada. All these changes, all these new chapters can feel exciting, but there's a cost to them, and we often don't think about the cost of moving to friendships, relationships. We're always looking forward, what's next? But I think we have to acknowledge the impact, those smaller losses. And, they can actually be a good training ground for the big losses. As physicians, we like to think of skills as a good thing. We could think of grief as a skill. Grieving well can be a skill that you can learn. If you can acknowledge smaller losses, those smaller changes, and process them and adjust to them when big events [00:05:00] happen, you're gonna be better prepared to go through that grief process.

Christine Ko: I like how you said that. Grief as a skill. To develop how to deal with it well is something that we can work on and improve ourselves in doing. What do you think are the components to that skill? 

Tony Subtil: Yeah. We learn in school the five stages of grief. Me, in terms of timeline and different stages, I didn't really feel that. For me, that paradigm wasn't very helpful. 

Stages that, oh, I'm supposed to be feeling I'm supposed to be bargaining now or whatever. In real life, and I think each person is different too, and they're gonna grieve differently as well. But they were designed or described for patients who are dying. They weren't meant for the people who lost the loved one. So those five stages of grief are actually more about that person as opposed to family members. But one paradigm that I like is, accept, process, adjust. First you have to accept the reality of the loss, you know, of the change. It helps you overcome the initial shock. The [00:06:00] processing part is the one that most people struggle with ' cause it's natural for some people to ignore the grief. Ignore the pain. You wanna avoid it, you wanna push it down. But I think we do have to process all those feelings that keep coming up. It will be different feelings at different times. It won't be just sadness. I think anger often shows up as well. We definitely have to feel them. Going through that process in isolation makes it even harder. So I think talking to someone, have some community in your grieving process, that can be very healing. And that can look different ways. It could be a friend who has lost someone as well. It could be a therapist who has experience with grief patients. Some religious organizations have small groups for people who are grieving. And I think that can be very healing as well, just knowing that you're not alone. Grief touches everybody. Different types of grief are just a human experience. Remember that you're not alone. Don't isolate yourself. 

Christine Ko: So you said accept, process, and what was the [00:07:00] third thing? 

Tony Subtil: The third thing is, thanks for reminding me, you kind of have to adjust to this new chapter, to this new world, these new circumstances. I like the idea of thinking of like a book with chapters, like life can be seen that way. There are different chapters. Things are always changing, right? We forget the impermanence of life. We know change will happen, but we hold on so tightly to everything. Then when any change happens, we have such a strong response and shock. In your book, the book of your own life, you don't wanna be stuck in a chapter, right? We are gonna get older, health problems happen, we're gonna lose loved ones. This chapter, this terrible thing happens, you lose someone, or you get divorced. Life goes on. You don't wanna just be stuck reading that same chapter over and over. But you do wanna acknowledge the ending of the chapter. And I think, again, accepting, processing, and adjusting can help with that.

Gratitude can be very helpful to close that chapter. I'm grateful for the good [00:08:00] times we had before the loss happened, and I think for the new chapter, I think trying new things can be very helpful, so maybe try to, add a sense of adventure to your life. In this new reality, is there something you can try? I think it can be healing as well in terms of moving forward and not getting stuck.

Christine Ko: Are you doing something new?

Tony Subtil: This year I started working with pottery, like ceramics. It has been fascinating, with the clay wheel. Creating a piece of pottery, from mud basically, and painting this piece that you yourself created. Yeah, I've made a bunch, already. That has been fun. Something low key, just for fun. It felt very childlike, like you're playing with mud, basically.

Christine Ko: That's cool. Pottery, neat. You mentioned the five stages of grief. Those are denial, anger, bargaining, depression, and then acceptance. But you're right, they really [00:09:00] based it on someone who gets a terminal diagnosis and they move through it. So it's probably a little different for us when we're dealing with something that's happened to us. But yeah, the last stage is acceptance so it ties in with what you were saying, accept, process, and then adjust. I also like how you put that because it ties in too with what you said first, that as doctors we're used to death. We're familiar with it, so we accept it, but whether we really process it, even when it happens to us in training.

Tony Subtil: Yeah. 

Christine Ko: I don't think we even fully process, at least I should say, when I was in training and some of the patients in my care did pass away, when I was an intern; some of them were very sick, they would pass, and our workload was still really heavy. There was never a time to mourn the patient, not at work anyway. People talked about this during COVID, that just droves of people passing away in the hospital, and there was never time to grieve them [00:10:00] as healthcare workers. So yes, I like how you put it. We not only need to accept something terrible happening, but process it in our way, and then adjust. Yeah, that's wise. 

Tony Subtil: It's good practice to just process any change, no matter how small it is. I think that's good preparation, for when the big stuff happens. 

Christine Ko: How do you process it? I don't even just necessarily mean you. I'm just thinking, how do I process things? For me, I have to sit with my emotions. A concrete example is if I feel like crying, I will cry. Not right away. I try not to cry in public, but when I'm... when there's a safe, appropriate space for me, I will cry over things, for sure. 

Tony Subtil: Yeah. I think that probably is gonna look different for different people. For me, journaling has been very helpful. Acknowledge what happened, go through the feelings, definitely feel the feelings. Don't block them. Don't ignore them. Don't avoid it. Exercise can be a good way [00:11:00] to physically express emotions that might be deep inside. Sometimes at the gym I would see an older woman that resembles my mom, and I would get emotional in the gym. So it's tough 'cause I went to the gym to let it out, but physically I don't wanna be crying in the gym. Another thing, therapy can be very valuable in helping you process things and move forward. It's important to pay attention to the other relationships in your life. Let's say if you lost a close one, you know the other people in your life want to help, but they're not sure how. Paying attention to the people that you are close to and telling them what you need. That might look differently at different times. Patience and time, right? It's hard, but it definitely gets better, especially if you process it and keep moving. I don't know if there's a easy recipe, but I think you don't wanna get stuck. 

Christine Ko: Yeah. You said it feels like an EKG wave, ups and downs and maybe more downs, especially in the beginning. But does it get better? 

Tony Subtil: Oh yeah, for [00:12:00] sure. Yeah. It definitely does, but it does take time. But I think not having expectations on yourself, oh, it has to be six months, it has to be within 12 months. So maybe not worry so much as the timeline but just be kind to yourself as you go through the process. We might have to pull back at times during that process. Something that has been helpful to me as well is learning how to say no. Especially in academia, we are often expected to say yes to everything, right? If you have an invitation, yes, the answer is always yes. And there can be a recipe before burnout. So I think there might be times when you're grieving that you do have to decline certain invitations, some certain requests. People are gonna totally understand. I heard the other day of the word no, meaning the initials "N" "O" as New Opportunity, so no equals new opportunity. Especially when you're grieving, saying no means saying yes to yourself. And creating space for new opportunities.

Christine Ko: I love that. New [00:13:00] opportunity is n "n" "o", no. That segues nicely into something else. Do you have tips on how to still thrive in a career, whether it's academic or otherwise, when you do have grief and you need to accept, process, adjust and sit with the grief?

Tony Subtil: Self-compassion can be very important. I think that kindness, we often thought should be kind, like show kindness externally to other people. But I think learning how to show kindness to yourself internally can be more challenging than showing kindness, externally.

Christine Ko: I like that. Do you have any final thoughts?

Tony Subtil: My final thought would be that grief is the price you pay for love and connection. I read that quote somewhere, and I thought that was a good way to describe grief. And Martin Prechtel defined grief as praise. Let me read that here. Grief is praise because grief is the natural way that love honors what it misses. Grief is [00:14:00] praise because grief is the natural way that love honors what it misses. I agree with that. It's hard, but it's worth it. That's the price we pay for the love, for the connection. If you're grieving, it's difficult, but it's a good sign. It means that there is connection, that there is love in your life, that now the grieving process is honoring. So I hope that we can all lead lives worthy of that grief. 

Christine Ko: Yes. That's a good way to end. Live a life worthy of grief. 

Tony Subtil: Yeah. It's worth it. 

Christine Ko: Thank you, Tony. 

Tony Subtil: Thanks for having me. I miss you. 

Christine Ko: I miss you, too.