Sunday, June 30, 2019

Strong empirical evidence for the fact that homeowners are happier than tenants; the effect seems to be robust over the years considered as well as for different specifications of our model

Are Homeowners Happier than Tenants? Empirical Evidence for Switzerland. Yvonne Seiler Zimmermann, Gabrielle Wanzenried. Wealth(s) and Subjective Well-Being pp 305-321, June 25 2019. Part of the Social Indicators Research Series book series (SINS, volume 76).

Abstract: Many people have a strong preference to own the house or apartment they are living in. Among other factors, homeownership is expected to affect the subjective well-being of individuals. Our paper analyzes the impact of homeownership on subjective well-being in Switzerland. Based on the data from the Swiss Houshehold Panel (SHP) over the time period from 2000 to 2016, we use a generalized ordered logit model to explain life satisfaction by a set of relevant factors including homeownership. Our results, which have been tested for robustness within several specifications, provide strong empirical evidence for the fact that homeowners are happier than tenants. This effect seems to be robust over the years considered as well as for different specifications of our model. In order to control for a potential reverse causality effect, we separately analyze the subsample of households that had a change in the homeownership but no changes with respect to other characteristics. The generated odds ratios confirm the positive impact of homeownership on people’s happiness and the absence of a reverse causality effect.

Keywords: Homeownership Subjective Well-being Generalized ordered logit models Reverse causality

Beauty, Gender, and Charitable Giving: Men donors will perceive attractive women as more likeable & deserving, while women donors will perceive attractive women as less needy & less deserving

Park, Jooyoung and Kim, Keongtae and Hong, Ying-Yi, Beauty, Gender, and Charitable Giving (June 18, 2019). SSRN:

Abstract: The authors retrieve data from a prosocial lending platform and conduct four experiments to examine the effects of facial attractiveness on charitable giving. The data show that facial attractiveness of women rather than men recipients more strongly affects donations and that donor gender determines whether beauty has positive or negative effects on charitable giving. Men donors will perceive attractive women as more likeable and deserving, while women donors will perceive attractive women as less needy and less deserving. The study highlights the importance of donor gender in understanding the impact of recipient attractiveness. The findings enhance understandings of beauty effects especially in the context of charitable giving and provide practical implications for individual recipients, charities and platform operators in sharing recipient images.

Keywords: attractiveness, beauty, charitable giving, crowdfunding, gender

What Suboptimal Choice Tells Us About the Control of Behavior

What Suboptimal Choice Tells Us About the Control of Behavior. Thomas R. Zentall. Comparative Cognition & Behavior Reviews, Volume 14: pp. 1–18.

Abstract: When animals make decisions that are suboptimal, it helps us to identify the processes that have evolved to produce this behavior. In an earlier article, I discussed three examples of suboptimal choice or bias (Zentall, 2016): (a) sunk cost, the tendency to continue on a losing project because of the amount already invested; (b) unskilled gambling, in which the loss is greater than the return; and (c) justification of effort, the bias to prefer conditioned stimuli that in training required more effort to obtain. Here I discuss three additional examples of suboptimal choice that we have studied in animals: (a) when less is better, in which animals prefer one piece of food (one preferred item) over two pieces of food (one preferred item plus one less preferred item); (b) suboptimal choice on the ephemeral choice task, in which animals prefer one piece of food now over two pieces of the same food, one now but the second briefly delayed; and (c) suboptimal choice in the midsession reversal task, errors of anticipation and perseveration. Each of these examples may help to identify the relative limits on behavioral flexibility found when animals are exposed to conditions that may be different from those that they would normally encounter in their natural environment. They also may help us to understand the origins of similar behavior when it occurs in humans.

Keywords: suboptimal choice, less is better, ephemeral reward, midsession reversal

Those of us who study the behavior of animals assume that they have evolved to maximize their success (e.g., at finding food), and much of learning theory (Skinner, 1938; Thorndike, 1911) is based on this premise. Animals select those responses that lead to the increased probability of reinforcement over those that do not. When animals’ behavior is consistent with this theory, it strengthens our belief in the validity of the theory. However, when animals show a preference for alternatives that result in less food over those that result in more food, it is important to try to understand why they do.

Kacelnik (2006) suggested that rationality in decision making can be defined in different ways. When defined by philosophers and psychologists, it has been judged in terms of the reasoning or thought processes that accompany the decisions. When defined by economists, it does not require thought processes but refers to behavior that is internally consistent and is compatible with expected utility maximization. When defined by biologists, it is broader and goes beyond the organism to allow for inclusive fitness (including benefit to one’s kin).

Sometimes, what appears to be an irrational choice may reflect a change in state. An animal’s preference for one kind of food over another may reverse if it has been sated on the preferred food, or an animal that has a choice between eating and being with conspecifics may choose the latter because being close to others may enhance feeding rate or may offer safety from predation (Kacelnik, 2006). Alternatively, the condition that the animal is in may cause it to choose less food over more food. For example, an animal may choose a low probability but possibly larger amount of food over a frequent but smaller amount of food but one that will not allow it to survive through the night (Stephens, 1981; see also Houston, McNamara, & Steer, 2007).

When animals prefer an alternative that provides them with less food over one that provides them with more (i.e., they choose suboptimally), on one hand, it may cause us to question the processes that underlie that behavior. In an earlier article in this journal (Zentall, 2016), I described a task in which pigeon showed a strong preference for one alternative that on 20% of the trials provided them with a signal for reinforcement and on 80% of the trials provided them with a signal for the absence of reinforcement, over a second alternative that always provided them with a signal for 50% reinforcement (Stagner & Zentall, 2010). With this procedure, not only do pigeons quickly show a preference for the 20% signaled over the 50% unsignaled reinforcement but they show no evidence that they learn to correct that preference with extensive training. Furthermore, that preference is not simply controlled by the uncertainty of the reinforcement associated with the higher probability of reinforcement alternative, because even when the alternatives are between 50% signaled reinforcement and 100% reinforcement, pigeons do not show a preference for the optimal alternative (McDevitt, Dunn, Spetch, & Ludvig, 2016; Smith & Zentall, 2016). In addition, a similar pattern of suboptimal choice can be shown when reinforcement magnitude is manipulated. For example, pigeons prefer a 20% chance of obtaining a signal for 10 pellets of food over a 100% chance of obtaining a signal for three pellets of food (Zentall & Stagner, 2011).

When animals choose suboptimally, it may tell us something about the natural environment in which the animals have evolved (Fortes, Pinto, Machado, & Vasconcelos, 2018). Several mechanisms may be responsible for this suboptimal choice. First, in nature, when an animal approaches a stimulus that signals the presence of food, it is likely that the probability of reinforcement will increase. Not so in this choice task in which choice frequency has no effect on the probability of reinforcement. Second, in nature, when an animal encounters a signal for the absence of food, that signal can generally be ignored, because the animal will simply reject it and look elsewhere for food (Fortes et al., 2018; Vasconcelos, Machado, & Pandeirada, 2018). That is, in nature there is no need to remain in its presence, so it does not acquire inhibitory value, whereas the animal must remain in its presence in the laboratory choice experiment.

Although the predictive value of the conditioned reinforcer that follows choice of each alternative, independent of its probability of occurrence, appears to predict choice (Smith & Zentall, 2016), evidence suggests that there may be a third factor (Case & Zentall, 2018; McDevitt et al., 2016). Case and Zentall (2018) found that when pigeons are given a choice between 50% signaled reinforcement and 100% reinforcement, they initially show indifference between the two alternatives; however, with continued training they show a significant preference for the suboptimal alternative (see also Kendall, 1974). Case and Zentall suggested that the preference for the suboptimal alternative may result from positive contrast between the expected value of reinforcement following choice of the suboptimal alternative and the value of the conditioned reinforcer that follows on half of the trials. Positive contrast would not be expected between choice of the optimal alternative and the conditioned reinforcer that follows, because the expected value of reinforcement is consistent with the value of reinforcement that follows. A similar mechanism was suggested by McDevitt et al. (2016), who proposed that the conditioned reinforcement that followed choice of the suboptimal alternative represented “good news,” whereas the conditioned reinforcement that followed choice of the optimal alternative was not newsworthy. Although identifying the predispositions responsible for suboptimal choice with this procedure will likely require further research, the inability of the pigeons to learn to choose optimally suggests that there are conditions under which pigeons do not appear to have the flexibility to overcome these predispositions.

In the earlier article (Zentall, 2016), I identified two other cases in which pigeons fail to choose optimally. The first was research on the sunk cost effect in which pigeons prefer to complete pecking on one reinforcement schedule over changing to another reinforcement schedule, even though changing to the other schedule would have reduced the time and effort (amount of pecking) to reinforcement. For example, pigeons first learned to peck 30 times for food when the color was green and 10 times for food when the color was red. They then learned that after pecking green a variable number of times, they would be given a choice between completing the pecks to green and switching to peck the red 10 times. Surprisingly, the pigeons preferred to return to pecking green, even when returning to green required as many as 25 more pecks (Pattison, Zentall, & Watanabe, 2012; see also Magalhães & White, 2014; Navarro & Fantino, 2005).

The second additional line of research described in the Zentall (2016) article actually involved a bias rather than a suboptimality. Pigeons were trained to peck a light to receive a choice between two colors. On some trials, a single peck was required and the choice was between, for example, red and yellow and choice of red was reinforced. On other trials, 20 pecks were required and the choice was between, for example, green and blue and choice of green was reinforced. On probe trials, pigeons were given a choice between red and green, the two colors both associated with reinforcement. Surprisingly, the pigeons showed a preference for green, the color that during training they had to work harder to obtain. When a similar effect has been found in humans (e.g., Aronson & Mills, 1959), it has been referred to as the justification of effort effect; however, we prefer to interpret this preference as a contrast effect. That is, the positive contrast between 20 pecks and green was greater than the positive contrast between one peck and red.

In the present article I examine three additional phenomena, each of which demonstrates a behavior that is suboptimal. The first is commonly referred to as the less is better effect; the second is the failure to learn to choose optimally on a task in which choice of one alternative provides two reinforcements, whereas the other provides only one (the ephemeral reward task); and the third is the failure to choose optimally on the midsession reversal task.

The Less Is Better Effect

Economists have traditionally held that when humans are given sufficient information, they generally make rational choices (Persky, 1995). This is the basis of rational choice theory (Becker, 1976). However, Tversky and Kahneman (1974) challenged this notion by showing that humans tend to use various affective heuristics in making decisions and those heuristics can be shown to lead to suboptimal decisions. Such an example is the less is better effect (sometimes referred to as the less is more effect), demonstrated in several experiments by Hsee (1998). In one example, Hsee asked subjects to estimate the value of a set of 24 dishes, all in good condition, or to estimate the value of a set of 40 dishes, but only 31 were in good condition. Surprisingly, the set of 24 dishes was valued higher than the set of 40 dishes. Apparently, the nine dishes of poor quality depreciated the value of the 31 good-quality dishes. The average quality of the set, as a whole, apparently overshadowed the objective judgment of the value of the set. But this effect may be unique to humans, who may be sensitive to the aesthetics of the two sets of dishes.

In another study, subjects were asked to imagine that a friend had given them a $55 wool coat from a store where coats cost between $50 and $500, or alternatively a $45 wool scarf from a store where scarves cost between $5 and $50 (Hsee, 1998). The subjects said that they would be happier with the scarf than with the coat because the purchase of the scarf would reflect greater generosity than the purchase of the coat. The scarf was at the high end of the range, whereas the coat was at the low end of the range. This finding suggests that if gift givers want their gift recipients to perceive them as generous, it would be better for them to give a high-value item from a low-value product category (e.g., a $45 scarf) than a low-value item from a high-value product category (e.g., a $55 coat).
Would animals show the same bias if food of different quality was used rather than dishes or clothing? According to optimal foraging theory (Stephens & Krebs, 1986), other factors being equal (e.g., the possibility of predation), nature should select against any tendency to prefer an alternative that provides less food. Kralik, Xu, Knight, Khan, and Levine (2012) tested this hypothesis. They found that monkeys readily would eat grapes and sliced cucumbers, but when offered a choice between them, they preferred the grapes. When the monkeys were offered a choice between a grape by itself or a grape and a slice of cucumber, however, they generally showed a strong preference for the grape alone.

A similar effect was found by Beran, Ratliff, and Evans (2009) for two of four chimpanzees when given a choice between a slice of banana and a similar slice of banana plus a slice of apple. Similarly, chimpanzees were indifferent between a preferred pellet and a similar pellet plus either a less preferred piece of carrot or a less preferred piece of apple (Sanchez-Amaro, Pereto, & Call, 2016). And when Beran, Evans, and Ratliff (2009) manipulated the quantity rather than the quality of the combined option, four chimpanzees preferred a 20 g slice of banana over the same 20 g slice of banana plus an additional 5 g slice of banana.

Dogs, too, have been found to show a less is better effect (Pattison & Zentall, 2014). Several dogs were found to eat a slice of carrot or a slice of cheese, but when given a choice, they preferred the cheese. However, when given a choice between the cheese and a combination of the cheese and the carrot, these dogs preferred the cheese alone (see Figure 1).

[full paper and figures in the link above]

Politicians/public figures often apologize after making controversial statements; it is assumed that they are wise to do so, but the public is either unaffected or becomes more likely to desire punishment

Hanania, Richard, Does Apologizing Work? An Empirical Test of the Conventional Wisdom (September 1, 2015). SSRN,

Abstract: Politicians and other public figures often apologize after making controversial statements. While it is assumed that they are wise to do so, this proposition has yet to be tested empirically. There are reasons to believe that apologizing makes public figures appear weak and risk averse, which may make them less attractive as people and lead members of the public to want to punish them. This paper presents the results of an experiment where respondents were given two versions of two real-life controversies involving comments made by public figures. Approximately half of the participants read a story that made it appear as if the person had apologized, while the rest were led to believe that the individual stood firm. In the first experiment, involving Rand Paul and his comments on the Civil Rights Act, hearing that he was apologetic did not change whether respondents were less likely to vote for him. When presented with two versions of the controversy surrounding Larry Summers and his comments about women scientists and engineers, however, liberals and females were much more likely to say that he definitely or probably should have faced negative consequences for his statement when presented with his apology. The effects on other groups were smaller or neutral. Overall, the evidence suggests that when a prominent figure apologizes for a controversial statement, the public is either unaffected or becomes more likely to desire that the individual be punished.

Keywords: Political psychology, polling, evolutionary psychology, pundits, public opinion, Donald Trump, political science

Heavy drinking is more prevalent in people aged 55-70 compared to those aged 23-54; in those aged 55-70 heavy drinking prevention should focus on the higher educated

Differences in alcohol use between younger and older people: Results from a general population study. Marjolein A. Veerbeek et al. Drug and Alcohol Dependence, June 29 2019.

•    Heavy drinking is more prevalent in people aged 55-70 compared to those aged 23-54.
•    Level of education of heavy drinkers differs between these age groups.
•    In those aged 55-70 heavy drinking prevention should focus on the higher educated.

Background: Prevention of problematic alcohol use is mainly focused on younger adults, while heavy drinking in middle-aged and older adults might be more frequent with more impact on functioning and health care use. Therefore, alcohol use and alcohol disorder in both age groups was compared. To facilitate age-specific prevention, it was examined whether risk factors of heavy drinking and impact on functioning and health care use differs across the life-span.

Methods: Data of people (23-70 years) were used from the Netherlands Mental Health Survey and Incidence Study-2 (N = 4,618), a general population-based cohort. Heavy alcohol use was defined as >14 drinks/week for women and >21 drinks/week for men. Alcohol disorder was defined as DSM-IV disorder of alcohol abuse and/or alcohol dependence. (Multinomial) logistic regression analyses were used to study risk factors of alcohol use and associations between alcohol use and health care use and functioning.

Results: The past-year prevalence of heavy alcohol was higher in older (55-70 years) compared to younger people (6.7% versus 3.8%), whereas alcohol disorder was less prevalent (1.3% versus 3.9%). Heavy alcohol use was associated with higher level of education in older adults compared to younger adults. Other characteristics of problematic alcohol use and its impact on functioning and health care use did not differ between age groups.

Conclusions: Heavy drinking is more prevalent among middle-aged and older people. Contrary to younger adults, prevention of heavy alcohol use in those aged 55-70 should focus on higher educated people.

There was a direct link between playing an instrument in their leisure time, during the day, & having more dreams including music; those dreams were more positively-toned regarding emotions

Music in dreams: A diary study. Nina König, Michael Schredl. Psychology of Music, June 29, 2019.

Abstract: In every culture and nation music has been mentioned as a sort of natural language. While the existence of dreams including music in musicians has been anecdotally reported, music in dreams have been rarely studied empirically. In the present study, 425 participants, mostly psychology students, reported their dreams in a dream diary for 14 days as well as the intensity of their dream emotions and answered a questionnaire about whether they play existing music or compose new music during the day. As expected, for persons playing an instrument in their leisure time, there was a direct link between playing an instrument during the day and having more dreams including music, thus confirming the continuity hypothesis of dreaming. In addition, dreams including music were more positively-toned regarding emotions than dreams in general. Further research might investigate, for example, whether dreams including music play a role in improving music performance skills.

Keywords: Music, dream, emotions, continuity hypothesis, playing an instrument

Acute carbohydrate consumption on mood: Some studies only reported results from questionnaire subscales that yielded significant differences while omitting those that did not

Fizzing out: no effect of acute carbohydrate consumption on mood. Michael D. Kendig, Margaret J. Morris. Neuroscience and Biobehavioral Reviews (2019) PII:S0149-7634(19)30362-8.


Policy interventions increasingly target sugar-sweetened beverage (SSB) consumptionto discourage excess sugar intakegivenevidence for detrimental effects on body weight, metabolic function, anddental health. Yet it is also interesting to consider other impacts ofSSBs, given ongoing debate around their effects on mood and alertness.

The systematic review and meta-analysis by Mantantzis and colleagues (2019)makes atimely contributionto this topic. The study collates results from 31 experiments (1259 participants, 176 effect sizes) onthe acute effects of carbohydrate-containing drinks on moodmeasures.The authors note that mood is often a secondary outcome about which few direct predictions are made.

In these experiments, participants are asked to consume a beverage containing carbohydrates beforere ceiving questionnaires asking how they feel, often alongside cognitive tests. The carbohydrate is typically a sugar such as glucose, sucrose, fructose, or some mix of these. In the mood questionnaires usedmost commonly,the Profile of Mood States (POMS) and Bond-Lader VAS (BL-VAS),participants ratehow strongly their current affective state aligns with a range of positive and negative emotions, either on 5-point (POMS) or visual analogue (BL-VAS) scales. Mantantzis et al.(2019)generate effect sizes for nine affective domains, which are then combined to form a composite score foroverall mood. The authors also compared studies that assessed mood 0-30, 31-60 or over 60 minutes after consuming carbohydrates, with a view to identifying underlying mechanisms. For example, Mantantzis et al.(2019) note that past research has shown that carbohydrate consumption increases levels of the serotonin precursor tryptophan, particularly after an hour post-consumption. Thus, stronger positive mood effects should be seen after an hour if tryptophan underlies this relationship.

Strikingly, there was no evidence for positive effects of carbohydrate consumption on mood, and few significant differences between carbohydrate and placebooverall. Carbohydrates significantly reduced alertness relative to placebo when assessed at 31-60 minutes, and significantly increased fatigue when assessed 0-30 minutes after consumption. No effects of carbohydrates were found at any interval onthe other seven domains. Contrary to authors’ hypotheses, heterogeneity between studies was low, despite substantial variability in carbohydrate dose and type.The only instance of high heterogeneity was on measures of fatigue assessed61+ min post-consumption. Follow-up analyses of moderator variables revealeda trend for carbohydrate to reduce fatigue in studies involving physically demanding tasks.On the composite score of ‘overall mood’, there was a marginally significant difference favouring carbohydrate over placebo after 60 minutes. However, the authors found trends towards publication bias at this interval, noting that some studies only reported results from questionnaire subscales that yielded significant differences while omitting those that did not, skewing the overall effect size. This resul tshould therefore be interpreted with caution.

Additionally, authors were unable to obtain effect sizes for ~40% of eligible articles(20/51), underscoring the need for improved data sharing practices. This new evidence that carbohydrate intake does not enhance mood, at least over the short-term,is consistent with an earlier meta-analysis (Wolraich et al., 1995) which found no evidence for effects of sugar on behaviou rin children.

By contrast, there is evidence for improved cognition following acute glucose intake,though these effects are sensitive to procedural variables such as fasting duration and glucose dose (reviewed by Riby, 2004). Moreover, extensive evidence from rodent studies indicatesthat diets high in sugar can impair aspects of learning and memory (Beilharz et al., 2016), and a recent study in people reported positive associations between self-reported sugar intake and depressive symptoms (Knüppelet al., 2017).

What might explain the discrepancy between the null results found by Mantantzis and colleagues and popular notions of the ‘sugar high’ or ‘sugar rush’? Several differences between controlled laboratory studiesand real-world scenarios are interesting to consider. One key factor is blinding: Participants were unaware of whether their drink contained carbohydrate or placebo (typically non-nutritive sweetener) in 25 of the 31 studies assessed by Mantantzis et al. (2019). Similarly, the meta-analysis by Wolraich et al. (1995) on sugar and activity in children included double-blind experiments. The use of blinding precludes expectancy effects, where in preconceived notions about the effects of sugar increase the tendency to see such effects.Yet one recent study found that even expecting sugar increased tension (Giles et al., 2018), suggesting that such expectancy effects may not always be positive. Second, in real-world settings SSBsare often consumed in environments or occasions that are rewarding,such as social gatherings and work breaks. Repeated consumption in these settings may producepositive associations between sugary drinks and positive mood–a centre piece of advertising strategies. In research studies the potential for contextual variables to influence mood is usually controlled or eliminated. Whereas study participants consume these drinks in isolation and often after a fast, day-to-day consumption of sugary drinks is often accompanied by solid foods, such as fast food meals, which may drive –or wash out –mood effects.

As SSBs typically contain caffeine, people may misattribute mood benefits to the carbohydrate rather than caffeine content. One factor that appears to warrant further investigation is palatability, which we believe is among the primary driversof sugary drink consumption.


We believe this contribution to research on diet and mood will inform public debate on sugar consumption. It adds important new evidence suggesting that sugar consumption has nopositive effects on mood, at least under the conditions used in these experiments, and appears to increase fatigue and lower alertness. This shifts the balance of evidence for sugar intake further towards harm and away from any beneficial effects.

Beilharz, J. E., Maniam, J., & Morris, M. J. (2016). Short-term exposure to a diet high in fat and sugar, or liquid sugar, selectively impairs hippocampal-dependent memory, with differential impacts on inflammation. Behav BrRes, 306, 1-7.

Frank, G. K., Oberndorfer, T. A., Simmons, A. N., Paulus, M. P., Fudge, J. L., Yang, T. T., & Kaye, W. H. (2008). Sucrose activates human taste pathways differently from artificial sweetener. Neuroimage, 39(4), 1559-1569.

Formulas for Grief?

Formulas for Grief. Johanna N Riesel, Harvard Plastic Surgery Residency Program, Boston, MA 02115, USA., Vol 393 June 29, 2019.

After 9 years of surgical training, I know how long a finger can survive if amputated from the body. I know how long you should wait before lifting something heavy after surgery. I can determine how much of a drug you need to treat your infection based solely on your bodyweight. There are algorithms for all of that. But I have no idea how long I am supposed to grieve the dead.Formulas exist throughout medicine to make patient care safer and less subject to human error. Despite these scientific gains, there are complexities to the human catalogue of emotions that we are unable to simplify with mathematical predictions. Scientists have studied grief for years, but missing from all of their publications is an algorithm that allows me to care for myself in the midst of drenching heartbreak while still trying to care for others as a practising surgeon. As of yet, there are no formulas for grief.2 years ago, I lost one of my closest friends. We shared a bond from childhood so strong, I often thought of him as my brother.

After a two-decade-long battle with cancer, after a life-saving bone marrow transplant from his sister, after a double lung transplant, after marrying his incomparable wife, after the birth of their beautiful daughter, Greg passed away. In a memorial held in his honour, I spoke about Greg and the connection we shared to a room of his family and friends. I blamed the tears and choking gasps of air that sliced through my speech on the fact that I had not slept since working a 24-h hospital shift the day before. The next morning, I flew home and went back to work.I did not know how long I was allowed to grieve. As a surgeon, I am not allowed to have a bad day in the operating room, but as a surgical resident, there is an unspoken governance that makes taking time off complicated. Our hospital workflow relies on surgical residents. There is no duplication built into this sys-tem, permitting a balance of hospital productivity and unshared case volume on which graduate medical education relies to train future physicians. Furthermore, the demands of the health-care system are such that taking time off is fraught with conflict and guilt. Patients rely on physicians to heal them, and to do it now, not a couple of months from now. We are drawn to this responsibility and pursue it, despite the costs, quietly enjoying the glorification that comes with sacrifice.

Despite all that we learn in residency, we are not taught to grieve, be it for our loved ones or for our patients. After a severe complication or the death of a patient, many surgeons are lucky to receive even a whisper of empathy from another surgeon. This is not meant to be callous but, rather, functional. For any surgeon, it can feel unbearable to recognise your own grief, old or new, and not look away. Instead, the general counsel is to return to work as soon as possible, a prescription that might paint over the residue of pain from our most difficult cases. Common surgical culture buoys us to “get back on that horse”, and keep our eyes straight ahead, protecting us from the scorch of reliving traumatic experiences. This teaching can spill beyond the walls of the hospital and into our personal lives. In this, it seems we are rarely given the allowance, be it from our mentors or ourselves, to fall apart. Instead, strength, which is often mere stoicism in masquerade, is honoured and instilled.

So, we clench our teeth and swallow the gulp of tears and anguish. We lock our slippery hearts behind the protection of our ribcages. We pour ourselves into the work. After all, work can be a blessing in that way: a distraction from our pain. If you try hard enough, it might let you separate from it completely, all under the feel-good-refrain of doing it for the patients. Eventually, the pain lessens. Or perhaps we are accustomed to it. Our nerve endings once on fire with melancholy now seem desensitised to its presence.In surgery, we are taught that “all bleeding stops eventually”. The body will send proteins and platelets to plug the geyser of blood flow, or, eventually, the body will run out of blood to bleed. I see grieving in medicine the same way. To function and to perform, physicians can plug the leaks in their avenues of emotion, lest they drown us in a flood of heartbreak.

In his years in and out of hospitals, Greg was haunted by the way humanity was chipped from residents and doctors in their pursuit of training and practice. At times, he saw that change in me as well. I struggled to explain my rationale to him. It was never to make myself cold or dissociated from my patients, but rather, to dissociate myself from my own feelings so I could make decisions without the clouded veil of sentiment. Thereafter, I would be left with just the facts, stripped of their human proprietors. If I tried to feel every loss, either of my own or of my patients, I feared that I would bleed out from the volume of cumulative trauma, and never come back to the hospital again. So, I tried to feel none of them.

Few things are more comforting to a surgeon than the control of haemorrhage.But in this fragile state, even the tiniest disturbance can “pop the clot”, yet another dictum of surgery that teaches doctors to tolerate a lower blood pressure so as not to disturb a freshly formed blood clot that had stemmed the tides of bleeding. In states of grief, one image, one word, one memory can disrupt whatever control we thought we had. Suddenly, we bleed. And we bleed for all of the losses we had before but never let ourselves feel. I make it just beyond the threshold of my apartment, and I howl.Greg’s death taught me that I could not tamponade my grief. Regardless of who you are or what you do, you have to step into your grief. It will toss you about and drag you to the ground. It will kick the air from your lungs. But through this tumult, it will take you to a place where, eventually, you can stand again. Ignored emotions will recur until they receive the attention they need. We have to grieve and experience our losses. The challenge remains: when and how?

Although hospitals have policies for bereavement leave, there is no policy for the burden your colleagues will bear covering for you in your absence. There is no policy to dictate the resolution of your own feeling of guilt for abandoning your patients, projects, and partners. Most policies are also written for immediate family members and do not extend to the loss of a dear friend.Or so I thought. When a co-resident died unexpectedly, I found myself engulfed by support from the faculty, administrators, and senior officials at our hospital. Our institution offered sponsored dinners, transportation to attend the funeral, and any time off the residents needed without question. I never knew these resources were not only available but also abundant. Still, I wondered if I had known about them, would I have used them when Greg died? In the middle of a departmental grief counselling session for my co-resident, a colleague stood, turned to walk out of the room, and said, “well, I think that’s enough already. Let’s get back to work”.

I will never know if he was unable to endure the anguish of that moment, or whether he simply thought it was a waste of time. What I did know was why I never felt comfortable asking for time to grieve. I realise now that it will be my choice to follow that example or to set my own.2 years after losing Greg, the grief has lessened. I walk through the hospital not holding my breath in an effort to suffocate tears, but rather thinking of what I need to do next. The grief that once filled my ears with its thunderous roar is barely a din. It is not entirely gone: its stains and stench, like cigarette smoke in a carpet, are evidence of its intransience.

There is a tree dedicated to Greg on his old college campus. Its bark is thick and gnarled, with large cracks that fracture through its trunk like scars mirroring its weathered life. Two of its larger branches have been sawed off. The remaining boughs continue to grow upward, and green leaves sprout above the neighbouring trees, hungry for survival. So much of this tree reminds me of Greg. On a recent trip to visit the tree, I pressed my back into its trunk, trying to imagine that I was leaning against Greg’s shoulder. But the fissures and knots in the bark were sharp and painful, and they pushed me forward as if to say keep moving, don’t stay here. After a moment longer under the tree’s canopy, I walked away, refusing to look back. When I got home, a long drive and a grocery trip later, I stooped forward to unpack my suitcase. A patter of knocks sounded on the hardwood beneath my feet, directing my attention to something that had fallen from my back. A piece of thick, splintered bark from Greg’s tree lay on my bedroom floor.I once heard that the depth of one’s grief is a reflection of the love that was experienced and lost. If that is truth, or even plausible theory, is the formula for grief a symbol of infinity

Despite the adage time heals all wounds, I know the science behind wound healing. The body cannot heal a wound without a scar. Scars are never as strong as the skin they used to be, and they can become thick and raised as if to ward off intruders that might sense their inherent weakness. But scars also show us the lives we have lived. They show us whom we have loved and how they have changed us. After knitting together the shreds of our hearts after a loss or a trauma, they act as the glue that shows the body’s inherent instinct to heal, even when we did not want it to. Science has never found a cure for scars. We cannot make them disappear.So, I kissed that little piece of bark, and I placed it on my dresser, where it sits today. I often forget that it is there until I catch sight of it as I rush to get ready for work in the early morning hours. In the seconds that transpire between sight and recognition, my senses fill with warmth and light. There is a gentle buzz that pushes me forward, a soft thrill from understanding the permanence of love.