Silent burdens: global perspectives on grief and psychological strain among neuro-oncology neurosurgeons.

Neuro-oncology neurosurgeons (NONs) manage patients with progressive neurological decline, make high-stakes decisions, and face repeated exposure to death. While burnout has been recognized as a significant concern, grief and psychological strain remain underexplored as related, partly overlapping phenomena. To address this gap, we convened an exploratory international cohort of NONs to develop a dialogue-informed perspective on grief. Insights from semistructured roundtable discussions were used to explore how grief and psychological strain are experienced, their key triggers, coping approaches, cultural influences, and perceived institutional and evidence gaps. Informed by these discussions-recorded, transcribed, and analyzed with a rapid thematic analysis-findings were synthesized into six themes: 1) The perception of grief and impact. We collectively view grief and psychological strain among NONs as arising not only from patient death, but also from iatrogenic neurological deficits and complications, reexposure to the patient's decline during follow-up, and the long relational trajectories characteristic of lower-grade glioma care. 2) Patterns in experiences of grief in NONs. Such experiences are understood to contribute to rumination, emotional blunting, social withdrawal, and exhaustion associated with sustaining realism while preserving hope. 3) NONs' coping with grief. Coping is similarly viewed as encompassing exercise and other "reset" routines, restoration of mastery through reflection and case review, reframing and meaning-making, selective peer support, compartmentalization, and graduated reexposure to lower-risk cases following adverse events. Career stage is regarded as a double-edged aspect, including a "lonelier at the top" experience. 4) Cultural differences in grief experiences. Grief is universal, but its expression and management vary via spiritual frameworks, end-of-life expectations, resources, medicolegal climate, and team psychological safety. 5) Lack of formal training and the hidden curriculum of grief and coping. NONs navigated these challenges largely by "learning by doing," with minimal formal guidance. 6) Institutional support, evidence gaps, and unintended harms. Institutional support is perceived as limited, with morbidity and mortality conferences variably buffering or intensifying distress depending on the degree of psychological safety. In this context, the cohort represented here emphasized the need for implementation of routine check-ins, mentorship structures, and psychologically safe debriefing after adverse events. Together, these reflections frame grief as a shared and discussable reality of neuro-oncology surgery practice; explicitly distinguish grief-related strain from burnout, describing significant burden even without burnout; and point toward actionable recommendations to support psychological safety and professional sustainability.