For medical school students, Benjamin Franklin's ubiquitous remark about death and taxes is particularly apropos. But while taxes will come into play years down the road, death is usually introduced on the very first day in the form of the cadaver you meet in Gross Anatomy. Death becomes more consequential, however, the first time a patient whose care you are directly involved with dies.

Perhaps you are part of the code team that tries unsuccessfully to revive him or her, or perhaps you simply find out about it after the fact. Either way, it is certain to happen. "It's going to happen, no matter what you do," says Dr. Frank Brincheiro, a family doctor practicing in Cambridge, Mass. "When you're in residency training, you are usually working in a hospital with really sick or older patients, patients who are more likely to die. That's when you see these things more often. All you can do is be prepared."

Brincheiro recalls the first time one of his patients died. "I was a fourth-year med student doing surgical rotation," he remembers. "One morning I came to the hospital extra early to see my first patient, an elderly man who had had a long hospital stay. I was walking into his room thinking, 'I'm going to write the perfect note,' and I see all these people walking out. It took a while for me to realize he had just coded and died. Here I am, focusing on being the perfect student and all proud of myself that I've gotten in there bright and early, and something much bigger had just happened--somebody's father had just died."

The patient's death, he says, shook his world view. "In medical school, you're focusing on, 'Am I doing this right?' It's very egocentric, and you can't help wondering, 'Could I have done something different?' Particularly when you're in training or a newly crowned attending, your feelings are more about self-doubt--what did I miss? You can't help feeling somewhat responsible, but at the same time you have to realize somebody is going through something worse, and it's not about you, it's about them."

Dr. Rebekah Chapnick, an internist who works with internal medicine residents at the outpatient clinic at MetroHealth Hospital in Cleveland, Ohio, says she doesn't remember the first patient she saw die. "When you're an intern, the first death you will see will be a code blue or a trauma," she says. "And the thing that you will remember the most is you are almost glad they died, because you are tired or you have other things you need to do, and now you get to go back to bed instead of dealing with a train wreck. No matter how sensitive and caring you think you are, you will need to deal with the fact that you just wanted to go back to sleep.

"Those aren't the ones people need to learn to deal with; it's more the first one who you think may have been your fault," she continues. "It's always technically someone else's fault when you're an intern, or even a resident. It's later when the deaths mean more to you, when you're the one being called in the middle of the night. I remember a guy very clearly who died a few weeks after discharge--I don't know what from, but I still wonder if it was my fault."

The crucial factor in dealing with a patient's death is talking about it, says Dr. Susan Dale Block, who is co-director of the Center for Palliative Care at Harvard Medical School and is also conducting research on how physicians react to their patients' deaths. "Debriefing after these early deaths is really critical, as without it, students and interns often experience high levels of emotional distress, grief, guilt, and uncertainty about whether an error was committed," she insists. "Debriefing should address the medical details related to the patient, how the family did, medical questions that remain unanswered, and personal concerns and emotions. Ideally, debriefing should be done by an attending physician and should attend, not only to the medical details, but to the learner's emotional response."

If a formal debriefing isn't forthcoming, Brincheiro advises that you seek out help from institutional sources or from fellow students. "When you are in a hospital setting, there are grievance and guidance counselors, and programs set up to help you deal with these things, as well as that informal network of people who are going through the same thing you're going through at the same time," he says. "I would strongly encourage leaning on those people, even though you're all competing with each other, especially when it's a catastrophic case you were involved with. You need that."

As your training advances, Brincheiro notes, it does get easier to handle a patient's death. "As you get more confident and you know what you're doing, you realize, 'I did everything I could, but it was going to happen.' After a while you can almost sense these things coming. In the end, we are all human--including doctors--and we're not going to be able to save everyone. You have to have that mindset going in. If you don't, you'll develop it. It's unavoidable."

That first death, he says, may be difficult, and the only thing you can do is know where to go for help. "You can't make it easier. Only time will make it easier," he declares. "Realize that other people are also going through it. The insecurity you're feeling, the self doubt, is something that every physician goes through, no matter what they look like on the surface."

Susannah Clark is a writer with the Next Generation and a post-bac student at Tufts University.