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To Cry or Not to Cry

Ben_3Ben Bryner -- I've been thinking about breaking bad news a lot lately, and an interesting article in the New York Times addressed that topic. Briefly, the author presents both sides of the issue of whether crying when delivering bad news is appropriate.

My scant experience with this kind of discussion (limited both in number of cases as well as limited by my student-level role and knowledge) has been that there's wide variability in these discussions, and therefore variability in the appropriate response. While the article tends to pigeonhole individual doctors as criers or non-criers, as Dr. Lerner concludes, it depends mostly on the individual patient. I'm sure all the people in the article do tailor their approach to each individual patient. And it's absolutely true that doctors can convey deep empathy without crying.

But the article takes the study by Dr. Anthony Sung (archived here, scroll down to page 5) a little out of context -- his survey found that a majority of third-year medical students and interns (69% and 74% respectively) had cried in a medical setting, but that "the most common reported cause for both students and interns was burnout," not from discussing bad news with a patient. Also, the abrupt shift in the article from talking about attendings to talking about students and interns is not a trivial difference; the role of an attending is very different than that of a trainee in this kind of situation.

Hopefully the following example will help explain what I mean by that.

I witnessed a very good example of breaking bad news on my neurology rotation. I had gotten to know a patient in his mid-50s with glioblastoma during clinic visits at the beginning of the rotation. At those visits he was talking about going back to work, but over the next couple of weeks his condition deteriorated. It became clear that the several experimental chemotherapy regimens he tried had failed, and that the chance of another regimen slowing down his disease progress was basically zero. He was admitted, and when his neurooncologist stopped by his room to tell him the results of the latest scan, I went with him.

The news was no real surprise to the patient and his wife, but it was still devastating when he heard that the scan was discouraging, the chemotherapy was not working, and that it was almost definitely not worth pursuing more chemotherapy. Importantly, the oncologist still left the option of chemotherapy out there for him to take if he liked, but included his recommendation against it. As the message set in, the patient and his wife began to cry, and so did the oncologist. It was a very appropriate display of emotion from the oncologist, I thought, and the patient later told me how much it meant to him. But I didn't feel like crying, and didn't feel like I needed to. It was fine that I was there, but our brief student-patient relationship was not enough to allow for my crying in that situation. If I had cried too it would have cheapened the experience for them, which was the last thing I would have wanted.

A doctor's emotional display also depends on the type of visit. In the above example, there was plenty of time to talk, the setting was quiet, and nothing needed to be done immediately. (Hospice care was arranged over the next couple of days). But in some of these discussions, especially in the ICU setting, practicalities dominate the conversation and the emphasis needs to be on helping the patient and family through difficult decisions. In these discussions, I can't remember the attendings ever crying, although they were compassionate, helpful, and empathetic towards patients without exception. And for all patients who have strong emotional relationships with their loved ones, those are far more beneficial than the most empathetic doctor's tears could ever be.

Another doctor is quoted in the article as saying it's not a doctor's job to cry with patients. I agree that that's not what a doctor's essential role is. The physician's role is to help the patient through difficult medical decisions (and perform procedures as necessary). Working with the patient, forming a team with him or her, carefully assessing what the patient knows and what he or she still needs to learn, and then making careful recommendations (sometimes very strong recommendations) are the true elements of compassion and empathy in the doctor-patient relationship. Whether the doctor cries or not while delivering bad news is only an outward manifestation of that relationship.

Which brings the topic back around to one of Dr. Lerner's original points, that medical school doesn't teach a lot of these things. Too often, we're taught about things on the superficial level -- what words to use, how close to sit to the patient, whether to cry or not. And while that's a good place to start, medical education has much further to go toward comprehensively preparing new doctors to develop empathic relationships with their patients.

April 25, 2008 in Ben Bryner | Permalink

Comments

Nice post Ben,

The issue of crying doctors is an important one. I appreciate how you unearthed the flaw in the study this article is based on.

Lately, I've been annoyed by the NYTimes' portrayal of medical education - especially this piece and the dermatology article several weeks ago. I have this vague sense that their reports are based on a small data set that are localized to a few geographical locations.

As an example, I think that there is a difference in acceptability of showing emotion on the West Coast vs. the East Coast. (Having not gone to medical school anywhere else than Seattle weakens my claim, of course!)

Posted by: Thomas Robey | Apr 27, 2008 8:50:56 PM

After working closely with a patient, I would feel strange if I didn't have any type of emotion when conveying bad news to a patient. Crying can run the whole spectrum from shedding a few tears to emotional outbursts and wailing. Shedding a few tears would never hurt one's reputation in such a serious situation. When I place myself in the patient's position, I would feel strange if the physician didn't show any emotion. I would be thinking "Who is this person: a robot? Are they trying to free up another bed?" I want my doctor to be an excellent physician AND a human, and as for my behavior, I expect no less from myself.

Posted by: CH | Apr 29, 2008 3:36:59 PM

Thank you for writing so thoughtfully and articulately about a complex topic.

Posted by: uyen-khanh | Apr 29, 2008 3:44:24 PM

I have been treating cancers and other dieseases. I am not affected to the extent of crying with older patients. I have cried with and wihtout parent when it involved children. Something about children which breaks your heart. I still have the memory of many children I treated and grive remembering their innovcence and their lack of understanging, that they are facing daath. I have talked to children of the patients who are also dying. It had the same emottional reaction but to a lesser degree. What can I say. It is human to react sepcially with the innocent who lack the knowledge of life and death.

Posted by: Dr.T.R. Shantha, MD, PhD, FACA | Apr 29, 2008 4:00:58 PM

Be honest. Be yourself.
Don't be an actor or actress.
Honesty and caring will assist the patient.
On a selfish note, I believe you will find patients are less likely to seek fault or sue if you are honest and caring. Just one opinion.

Posted by: EJ | Apr 29, 2008 5:37:21 PM

Ben: You write beautifully. Write a book some day! After reading your words and those in the Comments section, I'm now regreting I never asked my hospice patients, "How did your doctor tell you that your disease is no longer treatable? Did he/she cry when they told you?" because I could have learned so much from their responses.

Posted by: Nancy Chardt | Apr 29, 2008 5:38:56 PM

How strange. There is always room for empathy. Always. I'll always remember a well-known physician in my area. He was talking loudly and impatiently with the family of his long-term cancer patient who had just died. No tears. They left the office. He could barely contain his excitement when he dialed the BMW dealership and told the person on the other end "Yes- it just happened. He's finally in the bag! I'll pick it up after lunch- and make sure you've waxed it!" I think I actually saw tears of joy... I cancelled my appointment immediately and never went back.

Posted by: Alan Robertson, Jr. | Apr 29, 2008 5:52:25 PM

I've cried a couple of times as a medical student...but never in the presence of the patient. They were both patient deaths and I cried miserably at home for hours. These were back-to-back deaths. Secondary to this, I had insomnia and lost some weight afterwards. I didn't get well until I saw my primary MD and went through some behavioral changes. Apparently, I was grieving...alone For some reason, I slowly discovered that I am the type who bottles up emotional responses to bad news. As a male in my family, obvious display of emotion has always been discouraged as well (not a good idea now).

I have slowly learned how to let my emotions flow without being dramatic about it. Everything comes with experience. If I have a significant relationship with a patient, I will cry with them if my emotion response takes me there.

Posted by: John11 | Apr 29, 2008 7:30:05 PM

It has been my experience that true, honest emotion is essential to the effective practice of medicine today.
Having trained at the hands of the "old guard" (DeBakey et al) I can assure you that any display of emotion other than the barking of orders was frowned upon and would certainly have not been sanctioned.
Real life experience and a different set of values in a changing world has curbed any notion that one should behave in any fashion other than that which a situation demands. As a person I have most assuredly bonded with some patients more avidly than with others; there is no explanation except that this is part of our nature. As a result, I have experienced great highs and lows as the course of my patients lives and diseases have progressed.
We owe it to our patients and ourselves NOT to act dogmatically but authentically.

Posted by: Robert Marvin MD | Apr 29, 2008 8:36:56 PM

I've been an attending in emergency medicine for 9 years, and only one time did I break down when breaking bad news. As a man, I always felt it was taboo, and saved any tears I had for later. This one time, I lost a pediatric patient to severe head trauma from a MVA, and had to tell the mother that her baby was dying, and the tears flowed readily. She later sent me a thankyou note for my show of compassion and empathy. While I didn't solicit the tears willingly, and at the time was ashamed of my emotional display, it served a positive purpose and united us beyond the realm of physician and patient, and into the realm of our shared humanity.

Posted by: MJS_EmedMD | Apr 29, 2008 9:41:16 PM

I find that people cry when they have some connection to the Pt or family. Maybe a similarity to their own family. Having been on both sides of the grief spectrum, and cried with families and not with others I dont think its something that is that cut and dry that we can label as ok or not ok to do. From the Pts point of view, we are intimatly imbedded in their memory and strapped to the situation by the deep emotion that is hinged on our news. We all need to remember that our business is people and emotion is a part of that. The other side is that we cannot loose our souls in the grief that we are surrounded with. If you are repeatedly taking grief home then its time to get your emotion in check before it interferes with your own life.

Posted by: TG | Apr 30, 2008 7:00:34 AM

I've tried clicking on the link, but I can't seem to get to the article? Would be very interested in reading it, esp. since you say most other news articles are quoting it out of context. Cheers!

Posted by: Sheena | Apr 30, 2008 12:13:15 PM

After my sister's long hard fought battle with cancer, her oncologist had to break the news to us that she had come to the end of her battle. I will never forget that dear man as he put his face in his hands and then looked up with tears as he said he was sorry. That news would never be easy to hear but the fact that her doctor cared that much let us know that he had done all he could because he cared to do all that and then some. I am glad he was so human. I will never forget that moment in time or that special caring doctor. Tears are fine and they can be very helpful when they are genuine.

Posted by: E. Miller | Apr 30, 2008 12:13:53 PM

i think it`s so unprofessional to cry infront of a patient or the family!!!!!!

Posted by: | Apr 30, 2008 12:35:34 PM

You see I've got an emotion but I won't ever cry infront of my patient, NEVER. It would be most disappointing to THEM and their psyche. They are expected to cry.. it's their first experience, and some even had previous experiences with other family members or acquaintances, but, for a doctor seeing this many times, he should be firm, consoling but crying??! Look here the DOCTOR's crying now what is more DESPAIRING than THAT?? they want to hear things like; it's not the end of the world, say things about God's mercy, spiritual stuff ... I'd get deeply emotional, but NEVER CRY. Leave it for them.

Posted by: B Cairo | Apr 30, 2008 2:25:51 PM

i used to show support to the patient and his family then cry when i get home ,,,,infact i never cried before but now after my own sister survive a tumor ,,, i can feel them more and more ,but still NO CRYING !!

Posted by: dr.medicine_angel | Apr 30, 2008 3:35:03 PM

Cultural factors have to be taken into account. In the Asian context, patients and their relatives would be quite taken aback and highly uncomfortable if the doctor cried in front of them.

In any case, how is it that one can decide whether or not to cry?

Posted by: E | Apr 30, 2008 5:20:01 PM

I'm a PA student, not a medical student, but I have the same clinical rotations as all of you, and I have to say that I don't think the deeper issue here is whether or not we should be crying in front of patients; the issue is more this:

How can we constructively learn to deal with all the sickness, suffering and tragedy we encounter on a daily basis, and still remain compassionate, empathetic and not become hard, bitter and burned-out?


Posted by: Talia | Apr 30, 2008 6:50:10 PM

I think we have a few issues here:professionalism and honesty. Some think crying is unprofessional. Again it's not honest to hold your tears if you feeling emotional.How can one balance that? My own point of view is:As a patient,I'd rather get honest tears than a professional actor. After all, Doctors are humans and Medicine is a profession dealing with life saving. If someone wants to pretend they don't have feelings in the name of professionalism then they should choose a different career, maybe holywood.

Posted by: Val | Apr 30, 2008 7:06:00 PM

There are some very interesting points made on this discussion board. Surely crying is something that just occurs when the time is appropriate. In my experience, there are certain times when you have built up a close rapport with a patient over time and crying with them at one of the lowest points in their life can actually make them feel like their despair is justified, that they are not just another patient. I have had the unique experience of delivering a stillborn baby. How do you withdraw yourself enough from this experience not to cry when you have been with the parents in labour for possibly the worst 12 hours of their lives.

Posted by: M | Apr 30, 2008 7:06:26 PM

Ben, it was a true pleasure reading your article. Thank you for posting it and approaching a challenging subject, in my opinion. I think that doctors should definitely try not to hide behind a mask as long as this does not affect their lifes; I know doctors who were there for patients in desperate situations until their last hours of life without once crying and, yet, the family and patient appreciated his empathy, his support...crying or not depends so much on the personality of the doctor. It is very interesting how some doctors feel how their patients would like them to behave, how their patients are comfortable and show their feelings in a very discreet and yet honest way.

Posted by: Monica | May 1, 2008 1:28:39 AM

Hey all,

I agree that this is a very interesting and stimulating article. However, what most people seem to be suggesting is that to cry or not to cry is a decision over which we can make a choice. I disagree: if I reach a certain level of emotion I will cry - it's an all-or-nothing event. I can't cry on demand, nor can I stop at will, and I believe many people feel the same. Therefore, if I cry in front of a patient, it is because I truly feel that emotion, not because I have made a calculated decision that in this situation it is appropriate. While basic communication skills can be taught, the finer details must come from within - to do otherwise is overly-calculated.

Posted by: julia | May 1, 2008 2:51:47 AM

The article was nice. In medical field, we often encounter emotions from people. I guess as medical practitioner we also sympathize to the people who are affected but not to the extent that we cry. It's not about you don't care at all but sometimes crying or showing more emotions to a client made him feel more vulnerable and hopeless.

Posted by: joreen | May 1, 2008 3:50:01 AM

Crying is more of a spontaneous event than one that is planned or even controlled, so to cry or not to cry, whether you are a physician or not, really depends on how the emotional moment has impacted you--what triggered the tears. Once the body begins genuine tears during a cascade of neurological, hormonal, and metabolic factors, it's not easy to suddenly shut that down.

In the healthcare setting, particularly in care fields that see continual trauma and tragedy, I would expect a certain measure of secondary PTSD that might impact emotional response--on one hand it could be blunted or detached, on another it could give rise to more frequent outward manifests like tears.

Stress, fatigue, and depression are also factors that could influence the likelihood of tears. Although I don't believe anyone should be embarrassed by a natural emotional response, in a professional setting where tears are expected at a minimum I would think it might be healthy to self-examine the factors behind an emotional response (or lack of one), particularly if these episodes become more frequent. Tears may be purely spontaneous and healthy or they may be indicative of pathological coping issues that may have developed over time.

Posted by: btaylor | May 1, 2008 7:37:51 AM

crying is out of the question when a doctor cries in front of the patient whatever hope the patient has left imnmediately disappears.in most of the cases a simple gesture such as a hug or using the right words will solve the problem.when u cry u become emotionally involved with the patient and our own work performance decreases. a emotional firewall has to be built not just to protect the patient but to protect ourselves.coz we r humans and we do become depressed when someone dies or is about to die.

Posted by: James | May 1, 2008 8:22:35 AM

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